Mixed Categorical Flashcards
Which one of the following has been shown to be effective for improving symptoms of varicose veins? (check one)
A. Horse chestnut seed extract
B. Vitamin B12
C. Ephedra
D. Milk thistle
E. St. John’s wort
A
Horse chestnut seed extract has been shown to have some effect for symptomatic treatment of chronic venous insufficiency in that it relieves pain, tiredness, tension, and swelling in the legs. It contains a number of anti-inflammatory substances, including escin, which reduces edema and lowers fluid exudation by decreasing vascular permeability.
Milk thistle may be effective for hepatic cirrhosis. Ephedra is considered unsafe, as it can cause severe life-threatening or disabling adverse effects in some people. St. John’s wort may be effective for treating mild to moderate depression. Vitamin B12 is used to treat pernicious anemia.
The use of a corticosteroid inhaler in patients with stable chronic obstructive lung disease has been shown to: (check one)
A. increase the risk for osteoporotic fracture
B. increase the risk for pneumonia
C. produce no change in patients’ perceptions of quality of life
D. reduce overall mortality
B
The use of corticosteroid inhalers for COPD has received mixed reviews. Studies show an increase in the incidence of pneumonia, which is directly related to the dosage.
A 32-year-old G3P2 is in labor at term following an uncomplicated prenatal course. As you deliver the fetal head it retracts against the perineum. Downward traction fails to free the anterior shoulder. The most appropriate course of action would be to: (check one)
A. Apply increasingly strong downward traction to the fetal head
B. Have an assistant apply fundal pressure
C. Deliberately fracture the clavicle of the fetus
D. Begin an intravenous nitroglycerin drip
E. Place the mother’s thighs on her abdomen
E
Once it does occur, excessive force should not be applied to the fetal head or neck and fundal pressure should be avoided, as these manuevers are unlikely to free the fetus and can injure both mother and infant.
Up to 40% of shoulder dystocia cases can be successfully treated with the McRoberts maneuver, in which the maternal hips are flexed and abducted, placing the thighs up on the abdomen. Adding suprapubic pressure can resolve about half of all shoulder dystocias.
Additional maneuvers include internal rotation, removal of the posterior arm, and rolling the patient over into the all-fours position.
As a last resort, one can deliberately fracture the fetal clavicle, perform a C-section with the vertex being pushed back into the birth canal, or have the surgeon rotate the infant transabdominally with vaginal extraction performed by another physician.
General anesthesia or NTG, orally or intravenously, may be used to achieve musculoskeletal or uterine relaxation. Intentional division of the cartilage of the symphysis under local anesthesia has been used in developing countries, but should be used only if all other maneuvers have failed and a C-section delivery is not feasible.
A previously healthy 24-year-old female presents with a 10-day history of facial pain and fever. On examination she has tenderness over the maxillary sinus on the left.
Which one of the following would be most appropriate for treatment of this patient’s condition?
A. Intranasal saline flushes
B. Intranasal antihistamines
C. Oral antihistamines
D. Oral antibiotics
E. Reassurance only
D
Acute bacterial sinusitis (ABS) - duration of symptoms of at least 10 days without improvement should be treated with antibiotics, including both children and adults.
- Signs and symptoms may include nasal drainage and congestion, facial pressure and/or pain, sinus tenderness, and headache
- antibiotics
- amoxicillin or amoxicillin/clavulanate
- “respiratory” quinolone
- combination of a third-generation cephalosporin and clindamycin, particularly in patients with penicillin allergy
A 17-year-old soccer player presents for a preparticipation examination. His family history is significant for the sudden death of his 12-year-old sister while playing basketball, and for his mother and maternal grandmother having recurrent syncopal episodes.
His medical history and examination are completely normal. Prior to approving his participation in sports, which one of the following is recommended? (check one)
A. A resting EKG
B. A stress EKG
C. An echocardiogram
D. Pulmonary function testing
E. No further evaluation
A
A family history of sudden death and recurrent syncope is highly suspicious for genetic long-QT syndrome. It is best diagnosed with a resting EKG that shows a QTc >460 msec in females and >440 msec in males. This syndrome especially places young people at risk for sudden death. Management may include β-blockers, an implantable cardioverter-defibrillator, and no participation in competitive sports.
Dizziness is most likely to have a serious etiology when it (check one)
A. is associated with diplopia
B. is associated with intense nausea and vomiting
C. occurs when the patient rolls over in bed
D. occurs when the patient first arises in the morning
E. occurs after 2 minutes of hyperventilation
A
Diplopia, along with other neurologic symptoms such as weakness or difficulty with speech, suggests a central cause of vertigo and requires a complete workup.
Dizziness on first arising, dizziness with rolling over in bed, and dizziness with nausea and vomiting are consistent with peripheral causes of vertigo, such as benign positional vertigo. Dizziness that occurs after a couple of minutes of hyperventilation suggests a psychogenic cause.
Which one of the following Papanicolaou (Pap) test results is most likely to indicate a cancerous lesion? (check one)
A. Atypical squamous cells of undetermined significance (ASC-US)
B. Atypical squamous cells cannot exclude high-grade intraepithelial lesion (ASC-H)
C. Atypical glandular cells not otherwise specified (AGC-NOS)
D. Low-grade squamous intraepithelial lesion (LSIL)
E. High-grade squamous intraepithelial lesion (HSIL)
C
Pap tests are intended to screen for cervical cancer, but most abnormal Pap tests are associated with precancerous lesions or with no abnormality. The category of atypical glandular cells not otherwise specified (AGC-NOS) is associated with a 17% rate of cancer (8% carcinoma in situ and 9% invasive carcinoma).
High-grade squamous intraepithelial lesion (HSIL), which would seem worse intuitively, has only a 3% associated cancer rate.
Of the following, which one is the most common adverse event to complicate the hospital course of patients age 65 and over? (check one)
A. Falls
B. Wound infections
C. Drug-related events
D. Procedure-related events
E. Anesthesia-related events
C
It has been observed that drug-related problems are the most common type of adverse event, and for hospitalized patients the rate of these events increases with the patient’s age. One study showed that in patients who are >65 years of age, the number of events per 1000 discharges was 11.46 for drug-related events, 6.15 for wound infection, 3.85 for procedure-related events, 3.19 for falls, and 0.09 for anesthesia-related events.
A 60-year-old male has a drug-eluting stent placed in his right coronary artery. He will require treatment to prevent stent thrombosis, and once his initial treatment period is completed he will be placed on aspirin, 75–165 mg/day indefinitely.
Which one of the following is the preferred initial regimen for preventing stent thrombosis in this situation? (check one)
A. Aspirin/dipyridamole (Aggrenox) for 3 months
B. Aspirin, 162–325 mg/day for 3 months
C. Aspirin, 162–325 mg/day, plus clopidogrel (Plavix), both for 3 months
D. Aspirin, 162–325 mg/day, plus clopidogrel, both for 12 months
E. Warfarin (Coumadin) for 3 months
D
In patients with a drug-eluting stent, clopidrogel and aspirin is recommended for 12 months because of the increased risk of late stent thrombosis. After this time, aspirin at a dosage of 75–165 mg/day is recommended.
The minimum duration of combined therapy is
- 1 month for a bare metal stent
- 3 months for a sirolimus-eluting stent
- 6 months for other drug-eluting stents
A 27-year-old Korean female consults you regarding several painful ulcers she has developed in the vaginal area. Your examination reveals multiple 0.5-cm to 1.5-cm oval ulcers with sharply defined borders and a yellowish-white membrane. She denies recent sexual activity. Except for recurring aphthous ulcers of her mouth, her past history is unremarkable. You obtain blood for a CBC and serology. A Tzanck smear and culture of her ulcer is negative for herpes simplex virus. Two days later she returns to discuss her laboratory findings. She draws your attention to a pustule with an erythematous margin at the site where the venipuncture was done.
At this time the most likely diagnosis is: (check one)
A. Reiter’s syndrome
B. Behçet’s syndrome
C. syphilis
D. mucocutaneous lymph node syndrome (Kawasaki disease)
E. AIDS
B
Behçet’s syndrome - recurring genital + oral ulcerations + relapsing uveitis. It is more common in Japan, Korea, and the Eastern Mediterranean area, and affects primarily young adults. The cause is unknown.
Two-thirds of patients will develop ocular involvement that may progress to blindness.
Patients may develop arthritis, vasculitis, intestinal manifestations, or neurologic manifestations.
This disease is also associated with cutaneous hypersensitivity, where patients develop a sterile pustule with an erythematous margin within 48 hours of an aseptic needle prick.
Reiter’s syndrome is not associated with genital ulcers.
The ulcers of syphilis are characteristically painless.
Mucocutaneous lymph node syndrome (Kawasaki disease) primarily affects children under 6 years of age.
While AIDS causes distinctive skin lesions, genital ulcers are not a common manifestation of this disease.
Breastfeeding a full-term, healthy infant is contraindicated when which one of the following maternal conditions is present? (check one)
A. Chronic hepatitis B infection
B. Seropositive cytomegalovirus carrier state
C. Current tobacco smoking
D. Herpes simplex viral lesions on the breasts
E. Undifferentiated fever
D
Mothers with active herpes simplex lesions on a breast should not feed their infant from the infected breast, but may do so from the other breast if it is not infected. Breastfeeding is also contraindicated in the presence of active maternal tuberculosis, and following administration or use of radioactive isotopes, chemotherapeutic agents, “recreational” drugs, or certain prescription drugs.
You respond to a code blue in the obstetrics department. The patient is a 19-year-old primigravida at 35 weeks gestation, hospitalized with severe preeclampsia. A nurse anesthetist has placed an oral airway and is administering 100% oxygen to the apneic patient. She reports no difficulty ventilating the patient with a bag and valve, and no gagging with oral airway insertion. The patient’s blood pressure is 100/60 mm Hg and her pulse rate is 70 beats/min and regular. Her pupils are equal and sluggishly reactive, and she is flaccid and areflexic. The patient had been treated with a magnesium sulfate infusion and a recent bolus of labetalol. Which one of the following medications should you administer initially?
A. Calcium gluconate
B. Fosphenytoin
C. Labetalol
D. Lorazepam (Ativan)
E. Dopamine
A
During the treatment of severe preeclampsia with IV Mg, the presence of apnea + areflexia is most consistent with Mg toxicity. In addition to hemodynamic support, calcium infusion is recommended as an antidote.
- if central line -> calcium chloride (CENTRAL = CHLORIDE)
- if peripheral line -> calcium gluconate (PERIPHERAL = GLUCONATE)
Lorazepam, phenytoin, and fosphenytoin are less useful in preventing eclamptic seizures than magnesium. Labetalol is not indicated given the patient’s current blood pressure level. Dopamine, a pressor agent, is not indicated in this scenario, and could aggravate the patient’s preeclampsia.
A 68-year-old African-American female with primary hypothyroidism is taking levothyroxine (Synthroid), 125 μg/day. Her TSH level is 0.2μU/mL (N 0.5–5.0). She has no symptoms of either hypothyroidism or hyperthyroidism.
Which one of the following would be most appropriate at this point? (check one)
A. Continuing levothyroxine at the same dosage
B. Increasing the levothyroxine dosage
C. Decreasing the levothyroxine dosage
D. Discontinuing levothyroxine
E. Ordering a free T 4
C
Measurement of serum TSH is essential in the management of patients receiving levothyroxine therapy. In a patient receiving levothyroxine, a low TSH level usually indicates overreplacement. If this occurs, the dosage should be reduced slightly and the TSH level repeated in 2–3 months’ time. A free T4 level would also be unnecessary, since it is not as sensitive as a TSH level for detecting mild states of excess thyroid hormone.
A 35-year-old white female comes to your office with a 3-month history of the gradual onset of pain and tenderness in her wrists and hands. She also complains of 1 hour of morning stiffness. She denies rash, fever, or skin changes. On physical examination she has symmetric swelling of the proximal interphalangeal joints and metacarpophalangeal joints. Motion of these joints is painful. She has no rash or mouth ulcers. Radiographs of the hands and wrists are negative, and a chest film is unremarkable. A CBC is normal, but the erythrocyte sedimentation rate is elevated at 40 mm/hr. Latex fixation for rheumatoid factor is negative, and an antinuclear antibody (ANA) test is negative.
The most likely diagnosis in this patient is
A. rheumatoid arthritis
B. systemic lupus erythematosus
C. sarcoidosis
D. Lyme disease
A
This patient has RA by symptoms and physical findings and a test for rheumatoid factor is not necessary for the diagnosis. A negative RF does not exclude RA, and a positive RF is not specific. RF is found in the serum of approximately 85% of adult patients with RA; in subjects without RA, the incidence of positive rheumatoid factor is 1%–5% and increases with age.
The ANA test is positive in at least 95% of patients with SLE, but in only about 35% of patients with RA. Elevation of the ESR is seen in many patients with RA, and the degree of elevation roughly parallels disease activity.
At a mean of 6 months after the onset of Lyme disease, 60% of patients in the United States have brief attacks of asymmetric, oligoarticular arthritis, primarily in the large joints and especially in the knee.
A patient who takes fluoxetine (Prozac), 40 mg twice daily, develops shivering, tremors, and diarrhea after taking an over-the-counter cough and cold medication. On examination he has dilated pupils and a heart rate of 110 beats/min. His temperature is normal.
Which one of the following medications in combination with fluoxetine could contribute to this patient’s symptoms? (check one)
A. Dextromethorphan
B. Pseudoephedrine
C. Phenylephrine
D. Guaifenesin
E. Diphenhydramine (Benadryl)
A
Dextromethorphan is commonly found in cough and cold remedies, and is associated with serotonin syndrome given its actions as a nonselective SSRI. The risk of serotonin syndrome is especially high with concurrent use of SSRIs/MAOis.
A 16-year-old male accompanied by his mother presents to your outpatient clinic with concerns about his short stature and “boyish” looks. He is a sophomore in high school but is frequently mistaken for someone much younger. Radiographs reveal a bone age of 14.7 years. Which one of the following would suggest the need for further evaluation?
A. A family history of delayed growth
B. Height below the fifth percentile for age
C. Weight below the fifth percentile for age
D. Prepubescent testicular size
D
Most cases of short stature are due to constitutional growth delay, a term which implies that the child is normal but delayed in his development. A hallmark of this condition is being below the fifth percentile for height for most of childhood. Usually these children are thin and have a family history of delayed development. Bone age would be expected to be at least 2.5 standard deviations below the mean for agematched peers of the same chronologic age.
However, most experts agree that if no signs of puberty are seen by 14 years of age (no breast development in girls, no testicular enlargement in boys), then further workup for a more serious condition should be sought.
Other indications for evaluation would be no menarche in a girl by 16 years of age and underdeveloped genitalia in a boy 5 years after his first pubertal changes.
You see a 5-year-old white female with in-toeing due to excessive femoral anteversion. She is otherwise normal and healthy, and her mobility is unimpaired. Her parents are greatly concerned with the cosmetic appearance and possible future disability, and request that she be treated. You recommend which one of the following? (check one)
A. Observation
B. Medial shoe wedges
C. Torque heels
D. Sleeping in a Denis Browne splint for 6 months
E. Derotational osteotomy of the femur
A
There is little evidence that femoral anteversion causes long-term functional problems. Studies have shown that shoe wedges, torque heels, and twister cable splints are not effective. Surgery should be reserved for children 8-10 years of age who still have cosmetically unacceptable, dysfunctional gaits.
Major complications of surgery occur in approximately 15% of cases, and can include residual in-toeing, out-toeing, avascular necrosis of the femoral head, osteomyelitis, fracture, valgus deformity, and loss of position. Thus, observation alone is appropriate treatment for a 5-year-old with uncomplicated anteversion.
A 40-year-old white male presents with a 5-year history of periodic episodes of severe right-sided headaches. During the most recent episode the headaches occurred most days during January and February and lasted about 1 hour.
The most likely diagnosis is which one of the following? (check one)
A. Migraine headache
B. Cluster headache
C. Temporal arteritis
D. Trigeminal neuralgia
B
Cluster headache is predominantly a male disorder. The mean age of onset is 27–30 years. Attacks often occur in cycles and are unilateral.
Migraine headaches are more common in women, start at an earlier age (second or third decade), and last longer (4–24 hours).
Temporal arteritis occurs in patients above age 50.
Trigeminal neuralgia usually occurs in paroxysms lasting 20–30 seconds.
Of the following cardiovascular parameters, which one increases with normal aging? A. Maximum heart rate
B. Heart rate variability
C. Ejection fraction
D. Arterial wall elasticity
E. Blood pressure
E
As the body ages, the measured LVEF, HR variability, and maximum HR trend downward, the walls of the major aorta and major arteries stiffen, and the vasodilator capacity of most smaller vessels is reduced. The arterial wall changes increase peripheral resistance and result in an increase in BP.
A 22-year-old male has acute low back pain without paresthesias or other neurologic signs. There is no lower extremity weakness.
Which treatment has been shown to be of most benefit initially? (check one)
A. Complete bed rest for 2 weeks
B. Bed rest plus local injection of corticosteroids
C. A low-back strengthening program
D. Resumption of physical activity as tolerated
D
For patients who have acute back pain without sciatic involvement, a return to normal activities as tolerated has been shown to be more beneficial than either bed rest or a basic exercise program. Bed rest for more than 2 or 3 days in patients with acute low back pain is ineffective and may be harmful. Patients should be instructed to remain active. Injections should be considered only if conservative therapy fails.
A 6-month old Hispanic female has had itching and irritability for 4-5 weeks. There is a family history of atopy and asthma. Physical examination reveals an excoriated dry rash bilaterally over the antecubital and popliteal fossae, as well as some involvement of the face. In addition to maintenance therapy with an emollient, which of the following topical medications would be approporate first-line treatment for flare-ups in this patient. (check one)
A. A calcineurin inhibitor such as pimecrolimus (Elidel)
B. An anesthetic
C. An antihistamine
D. An antibiotic
E. A corticosteroid
E
This child has atopic dermatitis (ecxema). It is manifested by a pruritic rash on the face and/or flexural surfaces of the arms and/or legs. There often is a family history of atopy or allergies. In addition to the regular use of emollients, topical corticosteroids have been shown to be the best first-line treatment for flare-ups.
Topical cancineurin inhibitors should be second-line treatment for flare-ups, but are not recommended for use in children under 2 years of age. Antibiotics should be reserved for the treatment of acutely infected lesions. There is no evidence to support the use of topical anesthetics in the treatment of this disorder.
A 21-year-old female complains of bulging veins in her right shoulder region, along with swelling and a “tingling” sensation in her right arm that has developed over the past 2 days. There were no unusual events other than her regular workouts with her swim team. Ultrasonography confirms an upper extremity deep-vein thrombosis of her right axillary vein.
Which one of the following would be the most appropriate treatment? (check one)
A. Intravenous heparin for 72 hours, followed by oral warfarin (Coumadin) for 3 months
B. Low molecular weight heparin (LMWH) subcutaneously for 5 days only
C. LMWH subcutaneously for at least 5 days, followed by oral warfarin for 3 months
D. LMWH subcutaneously for at least 5 days, followed by oral warfarin indefinitely
E. Oral warfarin for 3 months
C
The FDA issued a boxed warning describing an increased risk of tendinopathy and tendon rupture associated with the use of which class of antibiotics? (check one)
A. Macrolides
B. Aminoglycosides
C. Fluoroquinolones
D. Tetracyclines
E. Polypeptides
C
Fluoroquinolones are associated with an increased risk of tendinopathy and tendon rupture. About 1/6000 prescriptions will cause an Achilles tendon rupture. The risk is higher in those also taking corticosteroids or over the age of 60.
You make a diagnosis of depression in a 26-year-old female. Her BMI is 32 kg/m² and she has been trying to lose weight. Which one of the following antidepressants would be LEAST likely to cause her to gain weight? (check one)
A. Mirtazapine (Remeron)
B. Amitriptyline
C. Bupropion (Wellbutrin)
D. Paroxetine (Paxil)
E. Citalopram (Celexa)
C
Bupropion is the antidepressant least likely to cause weight gain, and may induce modest weight loss. All of the other choices are more likely to cause weight gain. Among SSRIs, paroxetine is associated with the most weight gain and fluoxetine with the least. Mirtazapine has been associated with more weight gain than the SSRIs.
Which one of the following is the best INITIAL management for hypercalcemic crisis? (check one)
A. Intravenous furosemide
B. Intravenous pamidronate (Aredia)
C. Intravenous plicamycin (Mithramycin)
D. Intravenous saline
D
The initial management of hypercalcemic crisis involves volume repletion and hydration. The combination of inadequate fluid intake and the inability of hypercalcemic patients to conserve free water can lead to calcium levels over 14–15 mg/dL. Because patients often have a fluid deficiency of 4–5 liters, delivering 1000 mL of normal saline during the first hour, followed by 250–300 mL/hour, may decrease the hypercalcemia to less than critical levels (. If the clinical status is not satisfactory after hydration alone, then renal excretion of calcium can be enhanced by saline diuresis using furosemide.
IV pamidronate, a diphosphonate, reduces the hypercalcemia of malignancy and is best used in the semi-acute setting, since calcium levels do not start to fall for 24 hours. The same is true for intravenous plicamycin.
A 65-year-old male presents with a 1-month history of problems passing urine. He says that his bladder will feel full when he needs to urinate, but the urine stream is weak and his bladder does not feel as if it has emptied completely. The symptoms have become increasingly severe over the past week. Other symptoms include upper respiratory congestion for 3 days which he has treated with an over-the-counter decongestant with some relief, constipation with no passage of stool in the past 9 days, and increasing low back pain incompletely relieved with ibuprofen, with associated weakness in both legs. Examination shows a healthy-appearing male who is moderately overweight. He is afebrile and vital signs are normal. There is no abdominal tenderness and no masses are detected. A rectal examination reveals a large amount of hard stool in the rectum; a markedly enlarged (4+), boggy, tender prostate gland; laxity of the anal sphincter; and numbness in the perianal area. Urinalysis shows trace protein and 10-20 WBCs/hpf. Ultrasonography shows a post-void residual volume of 250 mL (normal for age A. Foley catheterization
B. Hospitalization for intravenous antibiotics
C. Digital disimpaction of the rectum, and Fleet enemas until clear
D. MRI of the lumbosacral spine
D
The differential diagnosis of urinary retention in the elderly is broad. While most causes are benign and readily treated, the physician must be vigilant in looking for conditions that require urgent intervention.This patient presents with many possible causes of urinary retention, with the most common being benign prostatic hyperplasia.
Acute prostatitis, especially in a male with an enlarged prostate, is another relatively common reason for obstructive symptoms. This patients physical examination and abnormal urinalysis support this diagnosis, but his normal vital signs and lack of fever suggest he can be treated with an oral fluroquinolone and does not require hospital admission for intravenous therapy.
Medications such as oral decongestants can contribute to urinary retention in men with enlarged prostate glands, and should be used with caution and discontinued if obstructive symptoms occur.
Obstipation with stool impaction is another relatively common reason for urinary retention in the elderly and can be treated with manual disimpaction and enemas.
In this patient, the presence of increasing low back pain and leg weakness, and the findings of anal sphincter laxity and numbness in the perianal area on examination, suggest cauda equina syndrome. Urgent diagnosis and treatment are necessary to reduce morbidity, and MRI should be performed immediately.
The presence of a mildly elevated post-void residual is not an indication for urgent decompression with a Foley catheter.
A 50-year-old male who is a heavy smoker asks you about vitamin supplementation to prevent cancer and cardiovascular disease. The patient is unwilling to stop smoking. According to the 2003 recommendations of the U.S. Preventive Services Task Force, which one of the following is true regarding vitamin supplementation in adults who are middle-age or older? (check one)
A. Large supplemental doses of ~17beta-carotene may increase the risk of lung cancer in heavy smokers
B. Beta-carotene supplementation decreases the risk of cardiovascular disease and cancer in nonsmokers
C. Supplementation with vitamins A, C, and E plus folic acid decreases the risk of cardiovascular disease
D. Supplementation with antioxidant combination vitamins plus folic acid decreases the risk of cancer
A
beta-carotene supplementation provides no benefit in the prevention of cancer in middle-aged and older adults. In two trials limited to heavy smokers, supplementation with beta-carotene was actually associated with a higher incidence of lung cancer and all-cause mortality
The probability of pregnancy after unprotected intercourse is the highest at which one of the following times? (check one)
A. 3 days before ovulation
B. 1 day before ovulation
C. The day of ovulation
D. 1 day after ovulation
E. 3 days after ovulation
B
There is a 30% probability of pregnancy resulting from unprotected intercourse 1-2 days before ovulation, 15% 3 days before, 12% the day of ovulation, and essentially 0% 1–2 days after ovulation. Knowing the time of ovulation therefore has implications not only for “natural” family planning, but also for decisions regarding postcoital contraception.
A 73-year-old female presents with complaints of dyspnea and decreasing exercise tolerance over the past few months. She says she has to prop herself up on two pillows in order to breathe better. She also complains of palpitations, even at rest. She has long-standing hypertension, but has not taken any antihypertensive medications for several years. She has no history of ischemic heart disease. On examination her blood pressure is 155/92 mm Hg, her pulse rate is 108 beats/min and irregular, and her lungs have bibasilar crackles. An EKG reveals atrial fibrillation, but no changes of acute ischemia.
Which one of the following would be most useful for determining her initial treatment? (check one)
A. A chest radiograph
B. Cardiac catheterization
C. Echocardiography
D. A TSH level
E. A D-dimer level
C
This patient’s history and clinical examination suggest heart failure. The most important distinction to make is whether it is diastolic or systolic, as the drug treatment may be somewhat different. An echocardiogram is the study of choice, as it will assess LV function.
Diastolic dysfunction - LVEF is normal / slightly elevated; more common in elderly females and patients with HTN, and less common in patients with a previous history of CAD. Diuretics and ARBs are useful treatments. Because of their effects on diastolic filling times, tachycardia and atrial fibrillation often cause decompensation in patients with diastolic heart failure.
At this time, cardiac catheterization is not indicated, and a stress test will not provide useful information. If the patient had systolic failure, a workup for ischemic disease would be needed, but most cases of diastolic dysfunction are not caused by ischemia. While hyperthyroidism can cause tachycardia and atrial fibrillation, the more immediate issue in this patient is the heart failure, which requires diagnosis and treatment. A pulmonary embolus can cause shortness of breath but usually has an acute onset, so a D-dimer level would not help at this time.
A 47-year-old male with chronic kidney disease is being treated with epoetin alfa (Procrit). His hemoglobin level is 11.3 g/dL (N 13.0-18.0). Which one of the following would be most appropriate with regard to his epoetin alfa regimen? (check one)
A. Increase the dosage until the hemoglobin level is >12.0 g/dL
B. Increase the frequency of injections, using the same dose
C. Decrease the frequency of injections, using the same dose
D. Continue the current regimen
D
In patients with renal failure, the risk for death and serious cardiovascular events is increased with higher hemoglobin levels (≥13.5 g/dL), and it is therefore recommended that hemoglobin levels be maintained at 10-12 g/dL. Studies have also demonstrated less mortality and morbidity when the dosage of epoetin alfa is set to achieve a target hemoglobin of
A 65-year-old white male comes to your office with a 0.5-cm nodule that has developed on his right forearm over the past 4 weeks. The lesion is dome shaped and has a central plug. You schedule a biopsy but he does not return to your office for 1 year. At that time the lesion appears to have healed spontaneously. The most likely diagnosis is (check one)
A. benign lentigo
B. lentigo maligna
C. basal cell carcinoma
D. squamous cell carcinoma
E. keratoacanthoma
E
Keratoacanthoma grows rapidly and may heal within 6 months to a year. Squamous cell carcinoma may appear grossly and histologically similar to keratoacanthoma but does not heal spontaneously. The other lesions do not resemble keratoacanthoma
A 23-year-old female nonsmoker has a history of an unusually high number of sinus infections and episodes of bronchitis. She has not required hospitalization, and the infections have not been due to a fungus or methicillin-resistant Staphylococcus aureus. Her growth as a child was normal, and she has a BMI of 24 kg/m2.
Which one of the following laboratory findings would be most likely?
A. An abnormal nitroblue tetrazolium test
B. Severe lymphopenia
C. Thrombocytopenia
D. Decreased serum levels of IgG, IgM, and IgA
D
Common variable immunodeficiency (CVID) is a disorder of humoral immunity associated with reduced serum levels of IgG, IgM, and IgA, and frequently presents as late as the third or fourth decade of life. The disorder is associated with recurrent sinus infections, otitis media, bronchiectasis, and chronic GI problems. Recognition of the disorder is important, as infections may be reduced when patients are treated with IVIg
Abnormalities in the other test results are compatible with less common primary immunodeficiencies. Lymphopenia suggests a disorder of cellular immunity such as severe combined immunodeficiency, thrombocytopenia suggests the Wiskott-Aldrich syndrome, and an abnormal nitroblue tetrazolium test suggests a phagocytic disorder.
A 40-year-old businessman has recently been diagnosed with irritable bowel syndrome after extensive testing by his gastroenterologist. His predominant symptoms are diarrhea and pain.
Which one of the following has been shown to be helpful in controlled trials? (check one)
A. Probiotics such as yogurt and buttermilk
B. Insoluble fiber such as wheat bran, corn bran, and defatted flaxseed
C. Soluble fiber such as psyllium (ispaghula)
D. Turmeric
E. Peppermint oil
E
Believe it or not, peppermint oil has been shown to relieve symptoms of diarrhea-predominent IBS.
A 48-year-old male who weighs 159 kg (351 lb) is admitted to the hospital with a left leg deepvein thrombosis and pulmonary embolism. Treatment is begun with enoxaparin (Lovenox).Which one of the following would be most appropriate for monitoring the adequacy of anticoagulation in this patient?
A. Anti-factor Xa levels
B. Activated partial thromboplastin time (aPTT)
C. Daily INRs
D. Daily factor VIII levels
A
In severely obese patients (>330 lb) and those with renal failure, low molecular weight heparin therapy should be monitored with anti-factor Xa levels obtained 4 hours after injection. Most other patients do not need monitoring.
In adults, which one of the following is the most likely cause of chronic, unilateral nasal obstruction? (check one)
A. Nasal septal deviation
B. Foreign body impaction
C. Allergic rhinitis
D. Adenoidal hypertrophy
A
The most common cause of nasal obstruction in all age groups is the common cold, which is classified as mucosal disease. Anatomic abnormalities, however, are the most frequent cause of constant unilateral obstruction. Of these, septal deviation is the most common.
Foreign body impaction is an important, but infrequent, cause of unilateral obstruction and purulent rhinorrhea. Mucosal disease is usually bilateral and intermittent. Adenoidal hypertrophy is the most common tumor or growth to cause nasal obstruction, followed by nasal polyps, but both are less frequent than true anatomic causes of constant obstruction.
Estimating the 10-year risk of developing coronary heart disease with the Framingham Heart Study Score Sheet would be most reliable when applied to which one of the following individuals? (check one)
A. A 19-year-old female with a strong family history of cardiac disease
B. An obese 50-year-old male with a history of a previous myocardial infarction
C. An otherwise healthy 36-year-old white male smoker
D. A postmenopausal 54-year-old female with angina
E. A 78-year-old male with a history of hypertension
C
Framingham Heart Study defined major risk factors for coronary heart disease: elevated BP, smoking, cholesterol levels, DM, and advancing age. Using measurements of each of these risk factors and consideration of the gender of the individual, a reliable determination of risk can be obtained in individuals 30–74 years of age who have no overt coronary heart disease. The largely white study population presumptively makes the risk determination most accurate for white patients.
A 16-year-old male is brought to your office by his mother for “stomachaches.” On review of systems, he also complains of headaches, occasional bedwetting, and trouble sleeping. His examination is within normal limits. His mother says that he is often in the nurse’s office at school, and doesn’t seem to have any friends. After some questions from you, he admits to being called names and teased at school. Which one of the following would be most appropriate? (check one)
A. Explain that he must try to conform to be more popular
B. Explain that these symptoms are a stress reaction and will lessen with time
C. Explore whether his school counselor has a process to address this problem
D. Order a TSH level
C
Childhood bullying has potentially serious implications for bullies and their targets. The target children are typically quiet and sensitive, and may be perceived to be weak and different. Children who say they are being bullied must be believed and reassured that they have done the right thing in acknowledging the problem. Parents should be advised to discuss the situation with school personnel. Bullying is extremely difficult to resolve. Confronting bullies and expecting victims to conform are not successful approaches. The presenting symptoms are not temporary, and in fact can progress to serious issues such as suicide, substance abuse, and victim-to-bully transformation.
Early palliative care in patients with a terminal disease, including symptom management, psychosocial support, and assistance with decision making, has been shown to: (check one)
A. shorten the time to death
B. increase aggressive end-of-life care
C. increase health care costs
D. decrease depressive symptoms
E. reduce the need for hospice
D
It has been shown that palliative care offered early in the course of a terminal disease leads to
- improvement in a patient’s quality of life and mood
- reduced aggressive end-of-life care and thus reduces health care costs.
- enables patients to enter hospice care earlier and perhaps for longer
- extend survival times in terminal patients
A 47-year-old postmenopausal female falls while carrying groceries into her house and sustains a right distal radial fracture. A chemistry panel reveals a calcium level of 11.2 mg/dL (N 8.6–10.6) and further evaluation leads to a diagnosis of primary hyperparathyroidism.
Which one of the following is the best course of treatment for this patient?
A. Estrogen replacement therapy
B. Long-term bisphosphonate therapy
C. Daily furosemide treatment with increased oral fluids
D. Elimination of calcium and vitamin D from the diet
E. Referral to a surgeon for consideration of parathyroidectomy
E
Hyperparathyroidism is usually caused by a single adenoma of one of the four parathyroid glands. Studies that localize the glands, such as a technetium scan or ultrasonography, enable surgeons to perform parathyroidectomy, thus achieving a cure rate of 95-98%.
In which one of the following scenarios would additional consent from a child’s parent or guardian be necessary prior to treatment? (check one)
A. A 6-year-old female with divorced parents who lives primarily with her mother is brought to the clinic by her father to discuss his concerns of possible abuse
B. An 8-year-old unconscious male is brought to the emergency department by a neighbor after falling out of a tree and striking his head
C. A 13-year-old male is brought to the clinic by a babysitter with a note giving permission to treat signed by a parent
D. A 15-year-old female who is considered emancipated under state law comes to your office to discuss family planning
E. A 16-year-old female who has driven herself to her clinic appointment reports a 2-day history of ear pain; she says her mother made this appointment for her
E
Children under the age of majority must have proof of permission to treat from a parent or guardian for non-emergent care. This does not apply to emergency situations in which a delay in care could result in serious harm.
A 25-year-old primigravida presents with sharp, stabbing, left-sided pelvic pain that started yesterday, 45 days after her last menstrual period. Her past history is not remarkable, and a physical examination is normal except for moderate tenderness in the left adnexa on pelvic examination. A urinalysis is normal, as is a CBC. Her beta-hCG level is 1500 mIU/mL. Assuming no adnexal mass is seen, which one of the following transvaginal pelvic ultrasonography findings would be consistent with the highest likelihood of an ectopic pregnancy? (check one)
A. Empty uterus: empty endometrial cavity with or without a thickened endometrium
B. Abnormal gestational sac: anechoic intrauterine fluid collection either >10 mm in mean sac diameter or with a grossly irregular border
C. Nonspecific fluid: anechoic intrauterine fluid collection D. Echogenic material: echogenic material within the endometrial cavity without a defined sac, or multiple discrete anechoic collections of various sizes divided by echogenic septations
A
At this time in the patient’s pregnancy, a gestational sac should be visible on ultrasonography. An empty uterus presents the highest risk (14%) for ectopic pregnancy, while nonspecific fluid and echogenic material are associated with a 5% and 4% risk, respectively.
An abnormal or normal sac is associated with no risk, with the rare exception of multiple pregnancies with one being heterotopic.
The results of a given study are reported as achieving significance at a p-value of
A. There is a 5% likelihood of the results having occurred by chance alone
B. If the study were replicated 100 times, 95 studies would repeat this finding and 5 would not
C. The confidence interval is 0%–10%
D. The null hypothesis has a 5% chance of being true
E. The β (type II) error is
A
The p-value characterizes the likelihood of achieving the observed results of a study by chance alone; in this study that likelihood 5% or less.
The confidence interval is a measure of variance and is derived from the test data.
The p-value in and of itself says nothing about the truth or falsity of the null hypothesis, only that the likelihood of the observed results occurring by chance is 5%.
The α // type I error is akin to the error of false-positive assignment; the β // type II error is analogous to the false-negative rate, or 1 – specificity, and cannot be calculated from the information given.
A 60-year-old male has moderate anemia, with a suggestion of hemolysis on a peripheral blood smear. Which one of the following patterns would be consistent with the presence of hemolysis? (check one)
A. Elevated LDH, decreased haptoglobin, elevated indirect bilirubin
B. Elevated LDH, elevated haptoglobin, decreased indirect bilirubin
C. Decreased LDH, elevated haptoglobin, elevated indirect bilirubin
D. Decreased LDH, decreased haptoglobin, elevated indirect bilirubin
E. Decreased LDH, decreased haptoglobin, decreased indirect bilirubin
A
Hemolytic anemia is established by reticulocytosis, increased unconjugated bilirubin, elevated lactate dehydrogenase (LDH), decreased haptoglobin, and peripheral blood smear findings.
A healthy 48-year-old female consults you about continuing the use of her estrogen/progestin oral contraceptives. She has regular menstrual periods, is not hypertensive or diabetic, and does not smoke. What advice would you give her? (check one)
A. She should stop the oral contraceptives
B. She should switch to a progestin-only pill
C. She should discontinue the contraceptive for 1 month, and if FSH is then elevated to postmenopausal levels, the pills should be stopped
D. She can safely continue to take the contraceptive if screening for thrombophilic conditions is negative
E. It is safe to continue the oral contraceptives
E
Healthy women may continue combination birth control pills into their fifties, and this patient has no contraindications. Screening for thrombophilic conditions is not indicated due to the low yield. FSH levels are not specific enough to evaluate the effect of stopping the contraceptive.
A 19-year-old female high-school student is brought to your office by a friend who is concerned about the patient having cut her wrists. The patient denies that she was trying to kill herself, and states that she did this because she “just got so angry” at her boyfriend when she caught him sending a text message to another woman. She denies having a depressed mood or anhedonia, and blames her fluctuating mood on everyone who “keeps abandoning her,” making her feel like she’s “nothing.” She admits that she has difficulty controlling her anger. Her sleep quality and pattern appear normal, as does her appetite. She denies hallucinations or delusions. The wounds on her wrists appear superficial and there is evidence of previous cutting behavior on her forearms. Her vital signs are stable.
Which one of the following would be most beneficial for this patient? (check one)
A. Clonazepam (Klonopin)
B. Fluoxetine (Prozac)
C. Quetiapine (Seroquel)
D. Inpatient psychiatric admission
E. Psychotherapy
E
This patient displays most of the criteria for borderline personality disorder. This is a maladaptive personality type that is present from a young age, with a strong genetic predisposition.
Borderline personality disorder is defined by high emotional lability, intense anger, unstable relationships, frantic efforts to avoid a feeling of abandonment, and an internal sense of emptiness. Nearly every patient with this disorder engages in self-injurious behavior (cutting, suicidal gestures and attempts), and about 1 in 10 patients eventually succeeds in committing suicide. However, 90% of patients improve despite having made numerous suicide threats. Suicidal gestures and attempts peak when patients are in their early 20s, but completed suicide is most common after age 30 and usually occurs in patients who fail to recover after many attempts at treatment. In contrast, suicidal actions such as impulsive overdoses or superficial cutting, most often seen in younger patients, do not usually carry a high short-term risk, and serve to communicate distress.
Inpatient hospitalization may be an appropriate treatment option if the person is experiencing extreme difficulties in living and daily functioning, and pharmacotherapy may offer a mild degree of symptom relief. While these modalities have a role in certain patients, psychotherapy (DBT) is considered the mainstay of therapy, especially in a relatively stable patient such as the one described.
A 70-year-old white female comes to your office for an initial visit. She has taken levothyroxine (Synthroid), 0.3 mg/day, for the last 20 years. A recent screening TSH was fully suppressed. What is she at risk for if this is untreated?
A. adrenal insufficiency
B. carcinoma of the ovary
C. carcinoma of the thyroid
D. hip fracture
E. renal failure
D
Women older than 65 years of age who have low serum TSH levels, indicating physiologic hyperthyroidism, are at increased risk for new hip and vertebral fractures. Use of thyroid hormone itself does not increase the risk of fracture if TSH levels are normal
A 50-year-old white female comes to you because she has found a breast mass. Your examination reveals a firm, fixed, nontender, 2-cm mass. No axillary nodes are palpable, nor is there any nipple discharge. You send her for a mammogram, and fine-needle aspiration is performed to obtain cells for cytologic examination. The mammogram is read as “suspicious” and the fine-needle cytology report reads, “a few benign ductal epithelioid cells and adipose tissue.”
Which one of the following would be the most appropriate next step? (check one)
A. A repeat mammogram in 3 months
B. Repeat fine-needle aspiration in 3 months
C. An excisional biopsy of the mass
D. Referral for breast irradiation
E. Referral to a surgeon for simple mastectomy
C
In the ideal setting, the accuracy of fine-needle aspiration may be over 90%. Clinical information is critical for interpreting the results of fine-needle aspiration, especially given the fact that the tissue sample is more limited than with a tissue biopsy. It is crucial to determine whether the findings on fine-needle aspiration explain the clinical findings. Although the report from the mammogram and the biopsy are not ominous in this patient, they do not explain the clinical findings. Immediate repeat fine-needle aspiration or, preferably, a tissue biopsy is indicated.
Proceeding directly to therapy, whether surgery or irradiation, is inappropriate because the diagnosis is not clearly established. Likewise, any delay in establishing the diagnosis is not appropriate.
A 40-year-old female comes to your office with a 1-month history of right heel pain that she describes as sharp, searing, and severe. The pain is worst when she first bears weight on the foot after prolonged sitting and when she gets out of bed in the morning. It gets better with continued walking, but worsens at the end of the day. She does not exercise except for being on her feet all day in the hospital where she works as a floor nurse. She denies any history of trauma. An examination reveals point tenderness to palpation on the plantar surface of the heel at the medial calcaneal tuberosity.
Which one of the following should you recommend as first-line treatment? (check one)
A. Taping/strapping
B. Over-the-counter heel inserts
C. Extracorporeal shock wave therapy
D. A corticosteroid injection
E. A fiberglass walking cast
B
Plantar fasciitis pain is typically located in the plantar surface of the heel and is worst when the patient first stands up when getting out of bed in the morning (first step phenomenon) or after prolonged sitting. The pain may then improve after the patient walks around, only to worsen after prolonged walking. Typical findings include point tenderness to palpation on the plantar surface of the heel at the medial calcaneal tuberosity where the calcaneal aponeurosis inserts. Radiographs are not necessary unless there is a history of trauma or if the diagnosis is unclear.
Condition may last for months-years and resolves in most patients over time w/ or w/o specific therapy. Treatments with limited evidence of effectiveness include off-the-shelf insoles, custom-made insoles, stretching of the plantar fascia, corticosteroid iontophoresis, custom-made night splints, and surgery (for those who have failed conservative therapy).
You are treating a 53-year-old female for a deep-vein thrombosis in her left leg. The use of compression stockings for this problem has been shown to: (check one)
A. increase the risk of pulmonary embolism
B. increase the level of pain
C. increase complications if used prior to completion of a course of anticoagulation therapy
D. decrease the risk of post-thrombotic syndrome
D
Post-thrombotic syndrome (PTS) is a complication of acute deep-vein thrombosis (DVT), and is characterized by chronic pain, swelling, and skin changes in the affected limb. Within 5 years of experiencing a DVT, one in three patients will develop PTS. The use of elastic compression stockings was associated with a highly statistically significant reduction in the incidence of PTS, with an odds ratio of 0.31
A 64-year-old white male appears to be depressed 2 weeks after hospital discharge for a myocardial infarction. He experienced short runs of ventricular tachycardia during his hospitalization, and echocardiography revealed an ejection fraction of 40% at the time of discharge, with no symptoms of heart failure. He has a history of depression in the past. His current symptoms include depressed mood, sleep disturbance, feelings of hopelessness, and anhedonia. He denies suicidal ideation.Which one of the following would be most appropriate at this point? (check one)
A. Low-dose amitriptyline at bedtime
B. Sertraline (Zoloft)
C. Referral for electroconvulsive therapy
D. Referral for intense interpersonal psychotherapy
B
Several studies have demonstrated that SSRIs are safe and effective in treating depression in patients with coronary disease, particularly those with a history of previous episodes of depression. Medications have performed significantly better than intensive interpersonal psychotherapy in this setting.
Electroconvulsive therapy is not considered first-line therapy in the absence of severe symptoms. While it may be effective for sleep disturbance, amitriptyline has potential cardiac side effects and is unlikely to be effective for the treatment of depression in low doses
A 70-year-old white female with osteoporosis sees you for follow-up a few days after an emergency department visit for an acute T12 vertebral compression fracture. The fracture was suspected clinically and on plain films; the diagnosis was confirmed with a bone scan. The emergency department physician prescribed oxycodone (OxyContin) and NSAIDs, but the patient is still experiencing considerable discomfort. In addition to increasing the dosage of oxycodone, which one of the following interventions would you suggest now to reduce the patient’s pain? (check one)
A. Calcitonin (Miacalcin)
B. Raloxifene (Evista)
C. Alendronate (Fosamax)
D. Physical therapy, including dexamethasone iontophoresis
E. Vertebroplasty
A
Calcitonin, either intranasal or subcutaneous, provides pain relief within a few days in many patients with osteoporotic vertebral compression fractures.
The remainder of the choices do not provide acute relief. Vertebroplasty/kyphoplasty procedures are generally reserved for cases in which medical management has failed.
A 16-year-old high-school football player plants his left foot to make a cut and feels his left leg give way. He feels a pop in the knee, followed by acute pain. He is evaluated on the field, and examination with the knee flexed 20° reveals that the tibia can be displaced farther anteriorly than with the uninvolved knee.
Which one of the following conditions is most likely?
A. Patellar tendon rupture
B. Posterior cruciate ligament tear
C. Anterior cruciate ligament tear
D. Tibial plateau fracture
E. Patellar dislocation
C
Anterior cruciate ligament (ACL) tears are the most common ligament injury requiring surgery. Females have a significantly higher rate of ACL tears, with the majority of tears in both men and women occurring without physical contact. In addition to the immediate problems, there is a significant increase in premature osteoarthritis of the knee. Findings that help make the diagnosis of ACL tear include a noncontact mechanism of injury, an audible popping sound, early swelling of the joint, and the inability to participate in the game after the injury. Many patients can walk normally and can perform such straight-plane activities as climbing stairs, biking, or jogging.
Physical examination using the Lachman test or pivot shift test can be used to further assess whether the ligament is torn. MRI can be used to confirm the diagnosis, although it is not needed if the diagnosis is clear from the history and examination.
A 34-year-old white female comes to the office for a Papanicolaou (Pap) test. On a review-of-system checklist, she checks “yes” to depressive symptoms, insomnia, and anxiety. On questioning, she admits to feeling depressed for about 4 months, after a recent job change. She is not suicidal. With probing, she admits that she repeatedly checks her locks and constantly worries about cleanliness; she has been this way “all of her life,” but finds it very time-consuming. Which one of the following drugs is the best choice for this patient? (check one)
A. Risperidone (Risperdal)
B. Clorazepate (Tranxene)
C. Clonazepam (Klonopin)
D. Imipramine (Tofranil)
E. Fluoxetine (Prozac)
E
The patient most likely has obsessive-compulsive disorder (OCD) with a depressive episode. SSRIs are most frequently used.
Risperidone and clonazepam are considered second-line drugs and are used as augmentation drugs when there is a partial response to an SSRI.
Staff members of an assisted-living facility ask for your advice regarding aerobic exercise programs for their older residents. The evidence is greatest for which one of the following benefits of physical activity in the elderly? (check one)
A. Maintaining weight after weight loss
B. Improving quality of sleep
C. Increasing bone density
D. Reducing the risk of falls
D
An 11-year-old male is brought to your clinic for follow-up after a recent will child visit revealed elevated blood pressure. The parents have restricted his intake of sodium and fatty foods during the last several weeks. His blood pressure today is 140/92 mm Hg, which is similar to the reading at his last visit. The parents checked the child’s blood pressure with a home unit several times and found it consistently to be in the 130s systolic and low 80s diastolic. The child had a normal birth history and has no known chronic medical conditions. Both of his parents and his two younger siblings are healthy. He is at the 75th percentile for both height and weight with a BMI in the normal range. He eats a balanced diet and is active.
What should be the next step for this patient?
A. Reassurance that this is likely white-coat hypertension
B. A goal weight loss of at least 5 lb
C. Evaluation for causes of secondary hypertension
D. Hydrochlorothiazide
E. Lisinopril (Prinivil, Zestril)
C
Hypertension in a patient this young should prompt a search for secondary causes, which are more common in young hypertensive patients than in adults with hypertension. The recommended workup includes blood and urine testing, as well as renal ultrasonography. An evaluation for end-organ damage is also recommended, including retinal evaluation and echocardiography.
During a comprehensive health evaluation a 65-year-old African-American male reports mild, very tolerable symptoms of benign prostatic hyperplasia, rated as a score of 7 on the American Urological Association Symptom Index. He has never smoked, and his medical history is otherwise unremarkable. Objective findings include an enlarged prostate that is firm and nontender, with no nodules. A urinalysis is normal and his prostate-specific antigen level is 1.8ng/mL.
Based on current evidence, which one of the following treatment options is most appropriate at this time?
A. Observation, with repeat evaluation in 1 year
B. Saw palmetto
C. An α-receptor antagonist
D. A 5-α-reductase inhibitor
A
Watchful waiting with annual follow-up is appropriate for men with mild BPH. PSA levels correlate with prostate volume, which may affect the treatment of choice, if indicated.
PSA >2.0 ng/mL for men in their 60s correlate with a prostatic volume >40 mL, for which 5 -reductase inhibitors is recommended, as they provide symptomatic relief for moderate to severe BPH symptoms.
A recent high-quality, randomized, controlled trial found no benefit from saw palmetto with regard to symptom relief or urinary flow after 1 year of therapy. The AUA does not recommend the use of phytotherapy for BPH. Surgical consultation is appropriate when medical therapy fails or the patient develops refractory urinary retention, persistent hematuria, or bladder stones.
A previously healthy 82-year-old male is brought to your office by his daughter after a recent fall while getting up to go to the bathroom in the middle of the night. The patient denies any history of dizziness, chest pain, palpitations, or current injury. He has a history of bilateral dense cataracts. On examination, he is found to have an increased stance width and walks carefully and cautiously with his arms and legs abducted. A timed up-and-go test is performed, wherein the patient is asked to rise from a chair without using his arms, walk 3 meters, turn, return to his chair, and sit down. It takes the patient 25 seconds and he is noted to have an “en bloc” turn.
Which one of the following is the most likely cause of this patient’s gait and balance disorder? (check one)
A. Visual impairment
B. Cerebellar degeneration
C. Frontal lobe degeneration
D. Parkinson’s disease
A
This patient has the cautious gait associated with visual impairment: slow, careful, “walking on ice” movements (a wide-based stance with abducted arms and legs // “en bloc” turns)
Patients with cerebellar degeneration - ataxic gait that is wide-based and staggering.
Frontal lobe degeneration - gait apraxia that is described as “magnetic,” with start and turn hesitation and freezing.
Parkinson’s - short-stepped and shuffling gait, with hips, knees, and spine flexed, and may also exhibit festination and “en bloc” turns.
Motor neuropathy - “steppage” gait resulting from foot drop with excessive flexion of the hips and knees when walking, short strides, a slapping quality, and frequent tripping.
“en bloc”: rather than the usual twisting of the neck and trunk and pivoting on the toes, patients keep their neck and trunk rigid, requiring multiple small steps to accomplish a turn.
A 4-week-old full-term male is brought to your office by his parents. They report that their child started vomiting just after his 1-week visit. The parents are concerned because they think the vomiting is worsening, occurring after every feeding, and “shooting across the room.” You note that the baby is afebrile, but has not gained any weight since birth. Based on this information, the most likely diagnosis is: (check one)
A. Formula intolerance
B. Meningitis
C. Viral gastroenteritis
D. Pyloric stenosis
E. Inappropriate feeding
D
Pyloric stenosis - characterized by the early onset of worsening projectile vomiting and poor weight gain, and occurs most often in full-term male infants who are otherwise healthy. Formula intolerance causes regurgitation, as would inappropriate feeding. Meningitis, whether viral or bacterial, would be associated with fever. Viral gastroenteritis is a common cause of vomiting in older children, and is usually associated with fever and diarrhea.
A 52-year-old white male is being considered for pharmacologic treatment of hyperlipidemia because of an LDL-cholesterol level of 180 mg/dL. Before beginning medication for his hyperlipidemia, he should be screened for: (check one)
A. hyperthyroidism
B. hypothyroidism
C. Addison’s disease
D. Cushing’s disease
E. pernicious anemia
B
Any person with elevated LDL cholesterol or any other form of hyperlipidemia should undergo clinical or laboratory assessment to rule out secondary dyslipidemia before initiation of lipid-lowering therapy.
Causes of secondary dyslipidemia include diabetes mellitus, hypothyroidism, obstructive liver disease, chronic renal failure, and some medications.
Which one of the following has been shown to have a beneficial effect for symptoms of the common cold in an adult?
A. Diphenhydramine (Benadryl)
B. Ipratropium (Atrovent) nasal spray
C. Intranasal zinc
D. Intranasal corticosteroids
E. Systemic corticosteroids
B
Ipratropium is the only nasally inhaled anticholinergic recommended for a cough caused by the common cold. One study showed that the nasal formulation decreases rhinorrhea and sneezing, and a Cochrane review found that ipratropium bromide nasal spray improved rhinorrhea but did not help nasal stuffiness.
Antihistamine monotherapy (either sedating or nonsedating) such as diphenhydramine was no more effective than placebo (SOR A). Corticosteroids have not been found to be effective for the symptoms of a common cold. Intranasal zinc should not be used because it may result in the permanent loss of smell.
Which one of the following medications is most effective for treating the arrhythmia shown?
A. Atropine
B. Bretylium tosylate (Bretylol)
C. Lidocaine (Xylocaine)
D. Procainamide (Pronestyl)
E. Adenosine (Adenocard)
E
Adenosine, an expensive IV drug, is highly effective in terminating many resultant supraventricular arrhythmias. Although it can cause hypotension or transient a-fib, adenosine is probably safer than verapamil because it disappears from the circulation within seconds.
Because of its safety, many cardiologists now prefer adenosine over verapamil for treatment of hypotensive supraventricular tachycardia.
Bretylium tosylate, procainamide, and lidocaine are used to treat ventricular arrhythmias.
Atropine is indicated in the treatment of sinus bradycardia.
A 47-year-old male who lives at sea level attempts to climb Mt. Rainier. On the first day he ascends to 3400 m (11,000 ft). The next morning he complains of headache, nausea, dizziness, and fatigue, but as he continues the climb to the summit he becomes ataxic and confused. Which one of the following is the treatment of choice? (check one)
A. Administration of oxygen and immediate descent
B. Dexamethasone, 8 mg intramuscularly
C. Acetazolamide (Diamox), 250 mg twice a day
D. Nifedipine (Procardia), 10 mg immediately, followed by 30 mg in 12 hours
E. Helicopter delivery of a portable hyperbaric chamber
A
The patient described initially showed signs of acute mountain sickness (anorexia, nausea, vomiting, insomnia, dizziness, or fatigue), but then deteriorated to high-altitude cerebral edema, defined as the onset of ataxia and/or altered consciousness.
The management of choice is a combination of descent and supplemental oxygen. Often, a descent of only 500-1000 m (1600-3300 ft) will lead to resolution of acute mountain sickness. Simulated descent with a portable hyperbaric chamber also is effective, but descent should not be delayed while awaiting helicopter delivery.
If descent and/or administration of oxygen is not possible, medical therapy with dexamethasone and/or acetazolamide may reduce the severity of symptoms. Nifedipine has also been shown to be helpful in cases of high-altitude pulmonary edema where descent and/or supplemental oxygen is unavailable.
Treatment with donepezil (Aricept) is associated with an increased risk for : (check one)
A. pulmonary embolism
B. liver failure
C. bradycardia requiring pacemaker implantation
D. cataract development requiring surgery
E. confusion requiring institutionalization
C
A large population study has established a significant increased risk of bradycardia, syncope, and pacemaker therapy with cholinesterase inhibitor therapy.
Elevation of liver enzymes with the potential for hepatic dysfunction has been seen with tacrine, but it has not been noted with the other approved cholinesterase inhibitors.
Cataract formation and thrombosis with pulmonary embolism do not increase with this therapy.
Although improvement in mental function is often marginal with cholinesterase inhibitor therapy, the therapy has not been shown to increase the need for institutionalization.
During a preparticipation examination of a 5-year-old male for summer soccer camp, his mother states that he frequently awakens during the night with complaints of cramping pain in both legs, and that he seems to experience this after a day of heavy physical activity. She says that he appears to drag his legs at times, but she has never noticed a definite limp. A physical examination of the hips, knees, ankles, and leg musculature is entirely normal.
Which one of the following would be the most appropriate next step in the evaluation and management of this patient?
A. Plain films of both hips and knees
B. Serum electrolyte levels
C. Recommending that he not participate in running sports
D. Reassurance, with no activity restrictions or treatment
E. Referral to a pediatric orthopedist
D
Benign nocturnal limb pains of childhood (growing pains) occur in many children, often between 4 - 6 yo. The etiology is unknown, but the course does not parallel pubescent growth, as would be expected if bone growth was the source of pain.
The pain often awakens the child within hours of falling asleep following an active day. The pain is generally localized around the knees, shins or calves, but also may affect the thighs and the upper extremities.
Reassurance that no additional tests or treatments are necessary and that the condition is self-limiting is the most appropriate response.
A 54-year-old female takes levothyroxine (Synthroid), 0.125 mg/day, for central hypothyroidism secondary to a pituitary adenoma. The nurse practitioner in your office orders a TSH level, which is found to be 0.1 mIU/mL (N 0.5-5.0). Which one of the following would you recommend? (check one)
A. Decrease the dosage of levothyroxine
B. Increase the dosage of levothyroxine
C. Order a free T4 level
D. Order a TRH stimulation test
E. Repeat the TSH level in 3 months
C
Although uncommon, pituitary disease can cause secondary hypothyroidism. The characteristic laboratory findings are a low serum free T4 and a low TSH.
A free T4 level is needed to evaluate the proper dosage of replacement therapy in secondary hypothyroidism. The TSH level is not useful for determining the adequacy of thyroid replacement in secondary hypothyroidism since the pituitary is malfunctioning.
In the initial evaluation of secondary hypothyroidism, a TRH stimulation test would be useful if TSH failed to rise in response to stimulation. It is not necessary in this case, since the diagnosis has already been made.
Which one of the following is most consistent with obsessive-compulsive disorder in adults? (check one)
A. Impulses related to excessive worry about real-life problems
B. A belief by the patient that obsessions are not produced by his or her own mind, but are “inserted” thoughts
C. Recognition by the patient that the obsessions or compulsions are excessive or unreasonable
D. Compulsions that bring relief to the patient rather than causing distress
E. Full remission with treatment
C
DSM-IV criteria for OCD indicate that the patient at some point recognizes that the obsessions or compulsions are excessive or unreasonable. The impulses of OCD are not related to excessive worry about one’s problems, and the patient recognizes that they are the product of his or her own mind. In addition, the patient experiences marked distress because of the impulses. Full remission is rare, but treatment can provide significant relief.
A 3-week-old male is brought to your office because of a sudden onset of bilious vomiting of several hours duration. He is irritable and refuses to breastfeed, but stools have been normal. He was delivered at term after a normal pregnancy, and has had no health problems to date. A physical examination shows a fussy child with a distended abdomen. Radiography of the abdomen shows a double bubble sign. Which one of the following is the most likely diagnosis? (check one)
A. Infantile colic
B. Necrotizing enterocolitis
C. Hypertrophic pyloric stenosis
D. Intussusception
E. Midgut volvulus
E
Volvulus may present in one of three ways:
- sudden onset of bilious vomiting and abdominal pain in a neonate
- history of feeding problems with bilious vomiting that appears to be a bowel obstruction
- failure to thrive with severe feeding intolerance.
The classic finding on abdominal plain films is the double bubble sign, which shows a paucity of gas (airless abdomen) with two air bubbles, one in the stomach and one in the duodenum. However, the plain film can be entirely normal. The upper gastrointestinal contrast study is considered the gold standard for diagnosing volvulus.
An 8-year-old male is brought to the emergency department with an acute asthma attack that began 48 hours earlier. His mother initiated his asthma action plan when the attack began, starting oral prednisolone plus albuterol (Proventil, Ventolin) by metered-dose inhaler with a spacer every 3–4 hours. In the emergency department the child is alert, with a respiratory rate of 30 beats/min and an oxygen saturation of 94% on room air. He is audibly wheezing. Peak flow is 40% of the predicted value. (check one)
A. Continue the current albuterol treatment but switch to a nebulizer
B. Administer high-dose albuterol via nebulizer every 20 minutes for 1 hour
C. Administer intravenous corticosteroids within the first hour
D. Administer magnesium sulfate intravenously
E. Prescribe high-dose mucolytics and chest physiotherapy
D
Repeated doses of a short-acting β2-agonist and correction of hypoxia are the main elements of initial treatment for acute asthma exacerbations in children. In children already receiving standard treatment with albuterol and corticosteroids the addition of intravenous magnesium sulfate has been shown to improve lung function and reduce the need for hospitalization.
Nebulizer treatments are no better than a metered-dose inhaler with a spacer. High-dose nebulized albuterol every 20 minutes for 1 hour has not been shown to be beneficial.
Oral administration of corticosteroids is as effective as the intravenous route for reducing the need for hospital admission (SOR A). Mucolytics and chest physiotherapy have not been shown to be effective in children with acute asthma attacks.
Which one of the following is true regarding medical errors? (check one)
A. Malpractice litigation is more common when physicians disclose errors to patients
B. The use of the word “error” should be avoided when disclosing mistakes to patients
C. Physicians in private practice are more likely to disclose errors to patients than physicians employed by institutions or health care organizations
D. Patients prefer to receive apologies and explanations when an error has been made
E. It is ethically defensible to only disclose an error if the patient is aware there is a problem
D
When a medical error has been made, patients prefer that their physician disclose the error and offer an explanation of events. Withholding that information from a patient is not ethical and is counter to standards set forth by various organizations. Using the word “error” is acceptable and does not lead to an increase in litigation. In fact, there is no evidence that malpractice litigation rates increase when an error is admitted, and rates often decrease. Private-practice physicians are less likely to admit errors to patients. It is surmised that these physicians have less access to training in disclosure than those employed by hospitals or health care organizations.
A 52-year-old female with a 60-pack-year history of cigarette smoking and known COPD presents with a 1-week history of increasing purulent sputum production and shortness of breath on exertion. Which one of the following is true regarding the management of this problem? (check one)
A. Antibiotics should be prescribed
B. Intravenous corticosteroids are superior to oral corticosteroids
C. Inhaled corticosteroids should be started or the dosage increased
D. Levalbuterol (Xopenex) is superior to albuterol
E. Acetylcysteine should be given if the patient is hospitalized
A
Antibiotic use in moderately or severely ill patients with a COPD exacerbation reduces the risk of treatment failure or death, and may also help patients with mild exacerbations.
Brief courses of systemic corticosteroids shorten hospital stays and decrease treatment failures. Inhaled corticosteroids are not helpful in the management of an acute exacerbation.
IV levalbuterol and albuterol have similar benefits and adverse effects.
Acetylcysteine, a mucolytic agent, has not been shown to be helpful for routine treatment of COPD exacerbations.
Which one of the following is NOT considered a first-line treatment for head lice? (check one)
A. Lindane 1%
B. Malathion 0.5% (Ovide)
C. Permethrin 1% (Nix)
D. Pyrethrins 0.33%/pipernyl butoxide 4% (RID)
A
LiNdaNe’s efficacy has waned over the years and it is inconsistently ovicidal. Furthermore, because of its Neurotoxicity, lindane carries a black box warning and is specifically recommended only as second-line treatment by the FDA.
A 56-year-old male with diabetes mellitus, hypertension, and chronic renal insufficiency presents for follow-up of his chronic medical conditions. Results of his most recent metabolic panel included an estimated glomerular filtration rate of 30 mL/min/1.73 m2 (N >60) and a calcium level of 10.4 mg/dL (N 8.5–10.2). Medication reconciliation reveals he is not taking the sevelamer (Renagel, Renvela) prescribed by the consulting nephrologist.
You explain to the patient that he should be taking sevelamer to lower his serum calcium. The drug accomplishes this by?
A. Blocking the effect of parathyroid hormone
B. Blocking excessive vitamin D levels, thus decreasing intestinal calcium absorption and increasing renal calcium excretion
C. Blocking intestinal absorption of phosphate, which lowers parathyroid hormone secretion
D. Directly blocking excessive calcium absorption in the intestines
E. Directly increasing the renal excretion of both calcium and phosphate
C
This patient has secondary hyperparathyroidism, a common cause of hypercalcemia in patients with chronic renal insufficiency. Sevelamer is a newer synthetic agent in the therapeutic class of phosphate binders, which includes calcium acetate. Decreasing serum phosphate lowers the feedback stimulation of parathyroid hormone secretion by the parathyroid gland, which is often excessive in chronic renal insufficiency. Normalizing parathyroid levels improves serum calcium levels.
An outbreak of pediatric diarrhea has swept your community. You evaluate a 30-month-old male who developed diarrhea yesterday. He is still breastfed. He is alert, his mucous membranes are moist, and his skin turgor is good. He passes a liquid stool in your office. Which one of the following would be the best advice with regard to his diet? (check one)
A. The mother should withhold breastfeeding
B. He should consume a normal age-appropriate diet, and continue breastfeeding
C. Fasting will promote intestinal mucosal recovery
D. Oral intake should be limited to clear fluids, bananas, rice, applesauce, and toast (BRAT diet)
B
Continued oral feeding in diarrhea aids in recovery, and an age-appropriate diet should be given. Breastfeeding or regular formula should be continued. Foods with complex carbohydrates (e.g., rice, wheat, potatoes, bread, and cereals), lean meats, yogurt, fruits, and vegetables are well tolerated.
Foods high in simple sugars (e.g., juices, carbonated sodas) should be avoided because the osmotic load can worsen the diarrhea.
Fatty foods should be avoided as well.
The BRAT diet has not been shown to be effective.
A 60-year-old male indicates that he occasionally brings up what appears to be undigested food long after his meal. He also admits that he sometimes chokes on food, and that his wife says he has bad breath. The most likely diagnosis is: (check one)
A. Achalasia
B. Esophageal reflux
C. Cancer of the esophagus
D. Zenker’s diverticulum
E. Large cervical bone spur
d
The combination of halitosis, late regurgitation of undigested food, and choking suggests Zenker’s diverticulum. Patients may also have dysphagia and weight loss. The diagnosis is usually made with a barium swallow. The treatment is surgical.
A 44-year-old female presents with a complaint of increasingly dry eyes over the past 3–4 months, and says she can no longer wear contacts due to the discomfort and itching. She also apologizes for chewing gum during the visit, explaining that it helps keep her mouth moist. On examination you note decreased tear production, decreased saliva production, and new dental caries. She stopped taking a daily over-the-counter allergy medication about 1 month ago.
Which one of the following is the most likely diagnosis? (check one)
A. Sarcoidosis
B. Sjögren’s syndrome
C. Ocular rosacea
D. Allergic conjunctivitis
E. Medication side effect
B
Sjögren’s syndrome - common systemic autoimmune diseases; results from lymphocytic infiltration of exocrine glands and leads to acinar gland dysfunction. A positive anti-SS-A or anti-SS-B antigen test or a positive salivary gland biopsy is diagnostic. In addition to ocular and oral complaints, clinical manifestations include arthralgias, thyroiditis, pulmonary disease, and GERD.
Most patients with sarcoidosis present with shortness of breath or skin manifestations, and patients with lupus generally have fatigue and joint pain. Ocular rosacea causes eye symptoms very similar to those of Sjögren’s syndrome, but oral findings would not be expected. Drugs such as anticholinergics can cause a dry mouth, but this would be unlikely a month after the medication was discontinued (
Your patient is in the second stage of labor, and you determine that the fetus is in face presentation, mentum anterior. Progress has been rapid and fetal heart tones are normal. You would now: (check one)
A. Perform an immediate cesarean delivery
B. Proceed with midforceps delivery
C. Anticipate vaginal delivery with close fetal monitoring
D. Manually convert to vertex presentation
C
Most infants with face presentation, mentum anterior, can be delivered vaginally, either spontaneously or with low forceps.
C-section is indicated for fetal distress and failure to progress.
Midforceps delivery is not indicated.
If fetal electrodes are attached, the chin is the preferred location.
A 72-year-old white male in otherwise good health complains of generalized pruritus that worsens in the winter. The itching is most intense after he bathes. He recently noticed a rash on his abdomen and legs as well. On examination you note poorly defined red, scaly plaques with fine fissures on the abdomen. No eruption is present at other pruritic sites. Which one of the following is the most likely cause of this problem? (check one)
A. Stasis dermatitis
B. Lichen simplex chronicus
C. Xerosis
D. Rosacea
E. Candidiasis
C
Xerosis is a pathologic dryness of the skin that is especially prominent in the elderly. It is probably caused by minor abnormalities in maturation of the epidermis that lead to decreased hydration of the superficial portion of the stratum corneum. Xerosis often intensifies in winter, because of the lower humidity and cold temperatures. Stasis dermatitis, due to chronic venous insufficiency, appears as a reddish-brown discoloration of the lower leg. Lichen simplex chronicus, the end result of habitual scratching or rubbing, usually presents as isolated hyperpigmented, edematous lesions, which become scaly and thickened in the center. Rosacea is most often seen on the face as an erythematous, acneiform eruption, which flushes easily and is surrounded by telangiectasia. Candidiasis is an opportunistic infection favoring areas that are warm, moist, and macerated, such as the perianal and inguinal folds, inframammary folds, axillae, interdigital areas, and corners of the mouth.
A 28-year-old white female consults you with a complaint of irregular heavy menstrual periods. A general physical examination, pelvic examination, and Papanicolaou test are normal and a pregnancy test is negative. A CBC and chemistry profile are also normal. The next step in her workup should be: (check one)
A. endometrial aspiration
B. dilatation and curettage
C. LH and FSH assays
D. administration of estrogen
E. cyclic administration of progesterone for 3 months
E
Abnormal uterine bleeding is a relatively common disorder that may be due to functional disorders of the hypothalamus, pituitary, or ovary, as well as uterine lesions, though younger women rarely have a structural uterine defects.
For women younger than 30 years old : once pregnancy, hematologic disease, and renal impairment are excluded, administration of intramuscular or oral progesterone will usually produce definitive flow and control the bleeding. No further evaluation should be necessary unless the bleeding recurs.
For older women, Endometrial aspiration, dilatation and curettage, and other diagnostic procedures are appropriate for recurrent problems or for older women. Estrogen would only increase the problem, which is usually due to anovulation with prolonged estrogen secretion, producing a hypertrophic endometrium.
A 31-year-old married white female complains of vaginal discharge, odor, and itching. Speculum examination reveals a homogeneous yellow discharge, vulvar and vaginal erythema, and a “strawberry” cervix. The most likely diagnosis is: (check one)
A. Candidal vaginitis
B. Bacterial vaginosis
C. Trichomonal vaginitis
D. Chlamydial infection
E. Herpes simplex type 2
C
Trichomonal vaginitis findings
- yellowish discharge which sometimes has a frothy appearance
- colpitis macularis (strawberry cervix)
Monilial/Candidal vaginitis classically causes a cheesy, whitish exudate with associated vaginal itching and burning. There may be vaginal and vulvar erythema and edema.
Bacterial vaginosis is characterized by a grayish discharge with few other physical signs or symptoms, if any.
Chlamydia may cause a yellowish cervical discharge and symptoms of pelvic inflammatory disease or, alternatively, may be totally asymptomatic.
Herpes simplex type 2 causes ulcerations on the vulva and vaginal mucosa which are exquisitely tender, often with marked surrounding erythema and edema.
A 48-year-old male presents with a 4-week history of rectal pain associated with minimal rectal bleeding. On examination there is a small tear of the anorectal mucosa at the 6 o’clock position.
The most appropriate initial treatment would be topical? (check one)
A. Botulinum toxin
B. Clobetasol (Temovate)
C. Capsaicin (Capzasin-HP, Zostrix)
D. Nitroglycerin
D
This patient has classic findings for acute rectal fissure. Although patients often require an internal sphincterotomy, nonsurgical measures that relax or dilute the sphincter have proven helpful.
Drugs that dilate the internal sphincter: diltiazem, nifedipine, and nitroglycerin ointment, have proven to be beneficial in healing acute fissures
Botulinum toxin injected into the internal sphincter has proven most beneficial, but topical preparations are not yet available and have not been shown to be effective for this problem. Corticosteroid creams may decrease the pain temporarily, but potent fluorinated corticosteroid creams such as clobetasol are not indicated in the treatment of fissure. Capsaicin cream can be helpful for pruritus ani, but not for anal fissures.
According to the Beers criteria, a list of drugs that should be avoided in geriatric patients, which one of the following NSAIDs should be avoided in older patients due to its higher rate of adverse central nervous system effects? (check one)
A. Indomethacin
B. Ibuprofen
C. Diclofenac sodium
D. Etodolac
E. Celecoxib (Celebrex)
A
The Beers criteria, a list of drugs that should generally be avoided by older patients, was developed by expert consensus, and was last updated in 2002. Indomethacin is on the list due to its propensity to produce more central nervous system adverse effects than other NSAIDs.
A 2-year-old white male is seen for a well child visit. His mother is concerned because he is not yet able to walk. The routine physical examination, including an orthopedic evaluation, is unremarkable. Speech and other developmental landmarks seem normal for his age.
Which one of the following tests would be most appropriate? (check one)
A. A TSH level
B. Random urine for aminoaciduria
C. Phenylketonuria screening
D. A serum creatine kinase level
E. Chromosome analysis
D
Diagnosis of Duchenne muscular dystrophy is usually not made until the affected individual presents with an established gait abnormality at the age of 4–5 years.
The disease can be diagnosed earlier by testing for elevated creatine kinase in boys who are slow to walk. Massive elevation of creatine kinase (CK) from 20 to 100 times normal occurs in every young infant with the disease. Early detection allows appropriate genetic counseling regarding future pregnancies.
Hypothyroidism and phenylketonuria could present as delayed walking. However, these diseases cause significant mental retardation and would be associated with global developmental delay. Furthermore, these disorders are now diagnosed in the neonatal period by routine screening. Disorders of amino acid metabolism present in the newborn period with failure to thrive, poor feeding, and lethargy. Gross chromosomal abnormalities would usually be incompatible with a normal physical examination at 18 months of age.
The most common cause of proteinuria in children is: (check one)
A. Acute postinfectious glomerulonephritis
B. Lupus glomerulonephritis
C. Hydronephrosis
D. Orthostatic proteinuria
E. Reflux nephropathy
D
Orthostatic proteinuria accounts for up to 60% of all cases of asymptomatic proteinuria reported in children, with an even higher incidence in adolescents.
Two doses of varicella vaccine are recommended for: (check one)
A. adults under 60 years of age who develop shingles
B. all children with normal immune status
C. only immunocompromised individuals
D. only children between 12 months and 13 years of age
B
Two doses of varicella vaccine are recommended for all children unless they are immunocompromised, in which case they should not be immunized against varicella, or with other live-virus vaccines.
Shingles is evidence of prior varicella infection and is a reason not to vaccinate with varicella vaccine.
Which one of the following treatmens is associated with a herald patch? (check one)
A. Pityriasis alba
B. Pityriasis lichenoides
C. Pityriasis rosea
D. Pityriasis rubra pilaris
E. Pityriasis (tinea) versicolor
C
In 50%–90% of patients, pityriasis rosea starts with an erythematous, scaly, oval patch a few centimeters in diameter. This is usually followed within a few days by smaller patches on the trunk and sometimes the proximal extremities.
Pityriasis rubra pilaris is a rare disease with five types. The classic adult type begins with a small red plaque on the face or upper body that gradually spreads to become a generalized eruption.
The other conditions listed typically begin with multiple lesions.
A 63-year-old white male sees you for an initial visit and is accompanied by his daughter, who is a patient of yours and scheduled the visit. The father recently relocated to be near the daughter after his wife died. He has well-controlled type 2 diabetes mellitus, but is otherwise healthy. Referring to the copy of the medical records they brought with them, the daughter notes that her father has received influenza vaccine in 3 of the past 5 years, but she can find no documentation that he ever had “the pneumonia vaccine.” She asks if he should receive it at this visit.
You advise them that he should receive pneumococcal vaccine: (check one)
A. annually, along with influenza vaccine
B. now and a repeat dose every 5 years
C. every 5 years starting at age 65
D. now and a repeat dose once at age 68
E. only once, at age 65
D
CDC recommends that all adults > 65 receive a single dose of pneumococcal polysaccharide vaccine.
Immunization before 65 is recommended for certain subgroups of adults, including institutionalized individuals; those with chronic cardiac or pulmonary disease, DM, asplenia, chronic liver disease, or kidney failure; and health-care workers. It is recommended that those receiving the vaccine before the age of 65 receive an additional dose at age 65 or 5 years after the first dose, whichever is later.
A previously healthy 20-month-old female is brought to the urgent-care clinic during the evening with a barking cough. On examination her rectal temperature is 37.9°C (100.2°F), respiratory rate 18/min, heart rate 120 beats/min, and O2 saturation 94%. She has stridor, with mild substernal retractions only when her temperature was taken. Which one of the following would be most appropriate at this point? (check one)
A. Dexamethasone, 0.6 mg/kg orally or intramuscularly as a single dose
B. Guaifenesin/pseudoephedrine elixir orally until symptoms improve
C. Azithromycin (Zithromax) orally for 5 days
D. Observation in the clinic, and if there is improvement, a 5-day course of dexamethasone
A
Croup is a syndrome most often caused by viruses, but can occasionally be of bacterial origin.
Mild croup is manifested by an occasional barking cough with no stridor at rest, and mild or absent intercostal retractions. Moderate croup presents with a more frequent barking cough, stridor with suprasternal and sternal retractions at rest, but no agitation. Severe croup includes more prominent inspiratory and expiratory stridor with agitation and distress.
Corticosteroids produce significant improvement - give as a single-dose dexamethasone (0.6 mg/kg PO or IM) OR 4 doses over a 2-day period. Longer courses of corticosteroids have not proven to be more effective and may be harmful, leading to secondary infections.
Children under 1 year of age should not be given honey because of possible contamination with which one of the following? (check one)
A. Staphylococcus aureus
B. Clostridium botulinum
C. Clostridium difficile
D. Escherichia coli
E. Hepatitis A
B
A 78-year-old male presents for a routine follow-up visit for hypertension. He is a smoker, but has no known coronary artery disease and is otherwise healthy. On examination you note an irregular pulse. An EKG reveals multiple premature ventricular contractions (PVCs), but no other abnormalities.
Current guidelines recommends against which one of the following? (check one)
A. Amiodarone (Cordarone) for suppression of PVCs
B. Flecainide (Tambocor) for suppression of PVCs
C. Evaluation for underlying coronary artery disease
D. No further evaluation or treatment
C
In patients with no known CAD, the presence of frequent premature ventricular contractions (PVCs) is linked to acute myocardial infarction and sudden death.
The Framingham Heart Study defines frequent as >30 PVCs per hour. AHA recommends evaluation for CAD in patients who have frequent PVCs and cardiac risk factors, such as hypertension and smoking. Evaluation for CAD may include stress testing, echocardiography, and ambulatory rhythm monitoring.
Strong evidence from randomized, controlled trials suggests that PVCs should not be suppressed with antiarrhythmic agents, as using encainide or flecainide to suppress PVCs increases mortality.
A patient who underwent coronary bypass grafting several months ago has been intolerant of all medications for cholesterol lowering. However, on the recommendation of a friend, he began taking red yeast rice that he purchased at a natural healing store. His cholesterol level has improved with this product and he has tolerated it so far.
You should consider monitoring which one of the following in this patient, based on the active ingredient in red yeast rice?
(check one)
A. WBC count
B. Platelet count
C. Prothrombin time
D. Liver enzymes
E. Kidney function tests
D
Red yeast rice (Monascus purpureus) is a Chinese herbal medication that is used as a dietary supplement, and as an alternative management of hyperlipidemia. Extracts of red yeast rice contain several active ingredients, including monacolin K and other monacolins, that have HMG-CoA reductase inhibitory activity and are considered to be naturally occurring forms of lovastatin. Red yeast rice extract lowers total cholesterol, LDL-cholesterol, and triglycerides. It may be useful for patients unable to tolerate statins due to myalgias, but requires periodic monitoring of liver enzymes because its metabolic effects and potential for consequences are similar to those of statins.
A 32-year-old female presents with complaints of moderate irritability and anxiety during the week before nearly all of her menstrual periods. During this time she also has problems with weight gain and breast tenderness. She says she is her “usual happy self” at other times during the month. You diagnose PMS.
Which one of the following complementary and alternative therapies has been shown to be helpful in reducing the symptoms of this problem?
A. Saffron
B. St. John’s wort
C. Soy
D. Pyridoxine (vitamin B6)
E. Vitamin E
D
Both pyridoxine (vitamin B6), 50–100 mg/day, and chasteberry, 20 mg/day, have been shown in randomized, controlled trials to reduce the symptoms of PMS compared with placebo. No good evidence supports the use of vitamin E, saffron, St. John’s wort, or soy.
A 7-year-old male is hospitalized after sustaining abdominal trauma in an accident. The child is conscious. His pulse rate is 150 beats/min, his systolic blood pressure is palpated at 60 mm Hg, and his respiratory rate is 40/min. His hemoglobin level is 4.0 g/dL because of trauma-related blood loss. His clinical condition is deteriorating despite an infusion of intravenous volume expanders, but the parents are Jehovah’s Witnesses and refuse to consent to a blood transfusion because of their religious convictions. Your prognosis is that without a blood transfusion the patient will die. According to medical-legal precedent, which one of the following is correct? (check one)
A. The patient should receive the transfusion regardless of the parents’ wishes
B. The patient can be transfused regardless of the parents’ wishes once he becomes asystolic
C. The parents may refuse the transfusion if they are in agreement
D. The parents may refuse the transfusion if the patient identifies himself as a Jehovah’s Witness
E. The parents may refuse the transfusion if there is a legally executed advance directive
A
The refusal to accept any medical intervention, including life-saving blood transfusions, has been well established for adults who have the ability to definitively communicate their wishes. Also, parents have the power to give or withhold consent to medical treatment on behalf of their children.
However, Western courts have deemed that parents cannot refuse emergency, life-saving treatment to children based on these principles: (1) the child’s interests and those of the state outweigh parental rights to refuse medical treatment; (2) parental rights do not give parents life and death authority over their children; and (3) parents do not have an absolute right to refuse medical treatment for their children, if that refusal is regarded as unreasonable.
An 8-year-old female is brought to your office because she has begun to limp. She has had a fever of 38.8°C (101.8°F) and says that it hurts to bear weight on her right leg. She has no history of trauma.
On examination, she walks with an antalgic gait and hesitates to bear weight on the leg. Range of motion of the right hip is limited in all directions and is painful. Her sacroiliac joint is not tender, and the psoas sign is negative. Laboratory testing reveals an erythrocyte sedimentation rate of 55 mm/hr (N 0–10), a WBC count of 15,500/mm 3 (N 4500–13,500), and a C-reactiveprotein level of 2.5 mg/dL (N 0.5–1.0).
Which one of the following will provide the most useful diagnostic information to further evaluate this patient’s problem?
(check one)
A. MRI
B. CT
C. A bone scan
D. Ultrasonography
E. Plain-film radiography
D
This child meets the criteria for possible septic arthritis. In this case US is recommended as it is highly sensitive for detecting effusion of the hip joint. If an effusion is present, urgent US-guided aspiration should be performed.
Bone scintigraphy is excellent for evaluating a limping child when the H/P, and radiographic and sonographic findings fail to localize the pathology.
CT is indicated when cortical bone must be visualized.
MRI provides excellent visualization of joints, soft tissues, cartilage, and medullary bone. It is especially useful for confirming osteomyelitis, delineating the extent of malignancies, identifying stress fractures, and diagnosing early Legg-Calvé-Perthes disease.
Plain film radiography is often obtained as an initial imaging modality in any child with a limp. However, films may be normal in patients with septic arthritis, providing a false-negative result.
You have decided that in addition to the counseling she has been receiving for depression, a 12-year-old female in your practice might benefit from an antidepressant medication. Which one of the following has shown the most favorable risk-to-benefit ratio in children and adolescents? (check one)
A. Fluoxetine (Prozac)
B. Lithium
C. Amitriptyline
D. Venlafaxine (Effexor)
E. St. John’s wort
A
SSRIs have been shown to benefit children and adolescents with depression, but there are concerns regarding their association with suicidal behavior. Fluoxetine seems to be the most favorable SSRI, and is the only one recommended by the FDA for treatment of depression in children 8–17 years old. There is limited or no evidence to support the use of lithium, venlafaxine, or St. John’s wort in children and adolescents. Amitriptyline and other tricyclic antidepressants are ineffective in children and have limited effectiveness in adolescents, and safety is an issue in both of these groups
A 13-year-old white female reports a 6-month history of intermittent abdominal cramping, with each episode becoming progressively worse. Based on her history, there is no obvious relationship to eating, voiding, or defecating. She reports that she has not yet begun menstruating and is not sexually active. Her weight has been stable. She appears to be in mild emotional distress about being “the last girl in her class to have a period.” She is in no physical discomfort and her vital signs are normal. Secondary sexual characteristics appear to be developing normally. She is in the 57th percentile for height and the 65th percentile for weight. A complete physical examination confirms your presumptive diagnosis. The therapeutic procedure of choice would be: (check one)
A. Appendectomy
B. Colonoscopy
C. Hymenotomy
D. Cystoscopy
E. Paracentesis
C
The key to making a diagnosis of imperforate hymen, aside from the obvious finding on physical examination, lies in the systematic drawing of inferences. One can speculate that this patient’s recurrent crescendo abdominal cramping represented six menstrual sheddings, with no egress from the body. Her delay in menarche, despite normal growth parameters, offers another clue that structural amenorrhea is present. Hymenotomy will relieve the pressure, and normal menses should ensue.
A 55-year-old white male smoker has had daily severe gastroesophageal reflux symptoms unrelieved by intensive medical therapy with proton pump inhibitors. A recent biopsy performed during upper endoscopy identified Barrett’s esophagus. Which one of the following is true about this condition? (check one)
A. It will regress after antireflux surgery
B. It will regress following esophageal dilation
C. It will regress after Helicobacter pylori treatment
D. It is associated with an increased risk of adenocarcinoma
D
Barrett’s esophagus = acquired intestinal metaplasia of the distal esophagus associated with longstanding GERD, although a quarter of patients with Barrett’s esophagus have no reflux symptoms. It is more common in white and Hispanic men over 50 with longstanding severe reflux symptoms, and possible risk factors include obesity and tobacco use. It is a risk factor for adenocarcinoma of the esophagus, with a rate of about one case in every 200 patients with Barrett’s esophagus per year.
Treatment is directed at reducing reflux, thus reducing symptoms. Neither medical nor surgical treatment has been shown to reduce the carcinoma risk.
One reasonable screening suggestion is to perform esophagoduodenoscopy in all men over 50 with gastroesophageal reflux disease (GERD), but these recommendations are based only on expert opinion (level C evidence), and no outcomes-based guidelines are available.
You suspect orthostatic hypotension in an elderly male who reports “dizziness” when standing up, and you decide to obtain recumbent and standing blood pressure measurements. After the patient rests in a supine position for 5 minutes, you measure his baseline blood pressure and then ask him to stand, which he does without a problem.
For how long should his blood pressure be periodically measured before considering the test complete? (check one)
A. 30 seconds
B. 60 seconds
C. 90 seconds
D. 3 minutes
E. 5 minutes
D
Orthostatic hypotension - drop in SBP ≥ 20 mm Hg or DBP ≥ 10 mm Hg diastolic that occurs within 3 minutes of standing. When symptomatic it is often described as lightheadedness or dizziness upon standing. Etiologies to consider include iatrogenic, neurologic, cardiac, and environmental causes, plus many others alone or in combination. Since orthostatic hypotension may result in syncope, leading to falls and substantial injury, identifying it and taking corrective steps can produce a significant benefit.
In patients with type 2 diabetes mellitus, intensive glycemic control has not been shown to be beneficial for which one of the following diabetic complications? (check one)
A. Peripheral neuropathy
B. Foot infections
C. Cardiovascular disease
D. Proliferative retinopathy
E. Nephropathy
C
Intensive management of hyperglycemia, with a goal of achieving nondiabetic glucose levels, helps reduce microvascular complications such as retinopathy, nephropathy, and neuropathy. Foot infections are less common in patients without neuropathy and in patients with good glycemic control.
Intensive management of hyperglycemia also has a beneficial effect on cardiovascular disease in patients with type 1 diabetes mellitus but, unfortunately, not in patients with type 2 diabetes. In fact, there is data to suggest 1c that intensive glycemic control (hemoglobin A
Which one of the following decreases the absorption of orally administered calcium supplements? (check one)
A. Taking calcium carbonate with meals
B. Taking calcium citrate with meals
C. Vitamin D supplementation
D. Proton pump inhibitors
D
Long-term H2-blocker or PPIs use is associated with decreased absorption of calcium carbonate. Patients taking these medications who require calcium supplementation should use calcium citrate to improve absorption. Calcium carbonate preparations should be given with a meal to improve absorption. Vitamin D is important in calcium absorption.
The earliest presenting symptom in most older patients with open-angle glaucoma is: (check one)
A. Unilateral eye pain
B. Unilateral eye redness
C. Unilateral visual loss
D. Tunnel vision
E. Double vision
D
About 3% of persons over age 55 have glaucoma, making it a leading cause of vision impairment. Although it is usually asymptomatic, the most common presenting symptom is tunnel vision, a gradual loss of peripheral vision.
A 72-year-old white male has new-onset hypertension with a current blood pressure of 190/110 mm Hg. Which one of the following agents can be used as part of a test for diagnosing renovascular hypertension, but would also increase the risk for azotemia if used for treatment? (check one)
A. Captopril (Capoten)
B. Metoprolol (Lopressor)
C. Clonidine (Catapres)
D. Furosemide (Lasix)
E. Amlodipine (Norvasc)
A
ACEi can significantly worsen renal failure in patients with HTN caused by renovascular disease. Hyperkalemia is an associated problem.
Captopril renography is a useful diagnostic screening test.
The other agents are useful for lowering blood pressure but may cause mild creatinine elevations. They do not, however, cause the significant elevations of creatinine seen with ACEi in cases of significant renovascular disease.
A 16-year-old sexually active nulliparous white female complains of pelvic pain and vaginal discharge. On examination she is 39.8 ˚C (102.0 ˚F), pain with movement of the cervix, and tenderness and a mass in the right adnexa. According to CDC guidelines, which one of the following treatments would be appropriate? (check one)
A. Outpatient treatment with penicillin G procaine (Wycillin) intramuscularly; probenecid (Benemid) orally; plus doxycycline (Vibramycin) orally for 14 days and reexamination in 3 days
B. Outpatient treatment with ceftriaxone (Rocephin) intramuscularly; probenecid orally; plus doxycycline twice a day for 14 days and reexamination in 1 week
C. Outpatient treatment with cefoxitin (Mefoxin) intramuscularly; plus doxycycline twice a day for 14 days and reexamination in 10 days
D. Hospitalization for treatment with cefoxitin intravenously and doxycycline orally or intravenously, then doxycycline orally twice a day to complete 14 days of treatment
D
Patients with PID and tubo-ovarian abscess (R adnexal mass) and high fever should be hospitalized and treated for at least 24 hours with IV antibiotics.
Amoxicillin/penicillin G procaine are no longer recommended because of the increasing prevalence of penicillinase-producing and chromosomally-mediated resistant N. gonorrhoeae.
If cefoxitin IM is used as an outpatient treatment, it should be combined with probenecid.
If ceftriaxone is used for outpatient treatment, probenecid is not required.
Reexamination should be done within 3 days of initiation of therapy.
A 25-year-old male has developed a painless ulcer on the glans of his penis. After an appropriate examination and testing you diagnose primary syphilis and treat him with 2.4 million units of benzathine penicillin intramuscularly in a single dose. Eight hours later, while you are working the evening clinic, he returns because he has a fever of 100.6°F and a bad headache, which he rarely gets. He says he “aches all over.”
Which one of the following would be most appropriate at this time?
A. Three blood cultures from different sites at 30-minute intervals
B. CT of the head
C. A lumbar puncture
D. Doxycycline, 100 mg orally twice a day for 14 days
E. Reassurance and antipyretics
E
This patient is experiencing the Jarisch-Herxheimer reaction, an acute, transient, febrile reaction that occurs within the first few hours after treatment for syphilis. The condition peaks at 6–8 hours and disappears within 12–24 hours after therapy. The temperature elevation is usually low grade, and there is often associated myalgia, headache, and malaise. It is usually of no clinical significance and may be treated with salicylates in most cases. The pathogenesis of the reaction is unclear, but it may be due to liberation of antigens from the spirochetes secondary to antibiotics effects.
Which one of the following reduces the incidence of atopic dermatitis in children? (check one)
A. Exclusive breastfeeding until the infant is 4 months of age
B. Prenatal ingestion of probiotics by the mother
C. Delayed introduction of solid food until after 6 months of age
D. Application of emollients
E. Early exposure to dust mites
A
Exclusive breastfeeding for the first 4 months of life has been shown to reduce the cumulative incidence of atopic dermatitis in the first 2 years of life for infants at high risk of developing atopic disease; doing so beyond 4 months does not appear to provide additional benefit.
Which one of the following treatments for type 2 diabetes mellitus often produces significant weight loss? (check one)
A. Exenatide (Byetta)
B. Glipizide (Glucotrol)
C. Pioglitazone (Actos)
D. Insulin detemir (Levemir)
E. Insulin lispro (Humalog)
A
“ex” those pounds!
Of the diabetic medications, only metformin and incretin mimetics/ exenatide have the additional benefit of helping the overweight or obese patient lose a significant amount of weight. Most of the other medications, including all the insulin formulations, unfortunately lead to weight gain or have no effect on weight.
An elevation of serum methylmalonic acid is both sensitive and specific for a cellular deficiency of which vitamin? (check one)
A. Vitamin A
B. Vitamin B 6
C. Vitamin B 12
D. Vitamin D
E. Folate
C
An elevation in serum methylmalonic acid is both sensitive and specific for cellular vitamin B 12 deficiency.
A previously alert, otherwise healthy 74-year-old African-American male has a history of slowly developing progressive memory loss and dementia associated with urinary incontinence and gait disturbance resembling ataxia. This presentation is most consistent with: (check one)
A. normal pressure hydrocephalus
B. Alzheimer’s disease
C. subacute sclerosing panencephalitis
D. multiple sclerosis
A
Normal pressure hydrocephalus - mild impairment of memory develops gradually over weeks/ months, accompanied by mental and physical slowness; condition progresses insidiously to severe dementia. Patients also develop an unsteady gait and urinary incontinence, but there are no signs of increased intracranial pressure.
Alzheimer’s disease brain gradually atrophies; disturbance in memory for recent events is usually the first symptom, along with disorientation to time and place; otherwise, there are no symptoms for some period of time.
Subacute sclerosing panencephalitis usually occurs in children and young adults between the ages of 4 and 20 years and is characterized by deterioration in behavior and work. The most characteristic neurologic sign is mild clonus.
Multiple sclerosis is characteristically marked by recurrent attacks of demyelinization; typical features of incoordination, paresthesias, and visual complaints. Mental changes may occur in the advanced stages of the disease. About two-thirds of those affected are between the ages of 20 and 40.
A patient in the first trimester of pregnancy has just learned that her husband has acute hepatitis B. She feels well, and her screening test for hepatitis B surface antigen (HBsAg) was negative last month. She has not been immunized against hepatitis B.
Which one of the following would be the most appropriate management of this patient?
A. No further workup or immunization at this time, a repeat HBsAg test near term, and treatment of the newborn if the test is positive
B. Use of condoms for the remainder of the pregnancy, and administration of immunization after delivery
C. Testing for hepatitis B immunity (anti-HBs), and immunization if needed
D. Administration of hepatitis B immune globulin (HBIG) now and hepatitis B vaccine after the first trimester
E. Administration of both HBIG and hepatitis B vaccine now
E
Hepatitis B immune globulin (HBIG) should be administered as soon as possible to patients with known exposure to hepatitis B. Hepatitis B vaccine is a killed-virus vaccine and can be used safely in pregnancy, with no need to wait until after organogenesis.
This patient has been exposed to sexual transmission for at least 6 weeks, given that the incubation period is at least that long, so it is too late to use condoms to prevent infection. The patient is unlikely to be previously immune to hepatitis B, given that she has no history of hepatitis B infection, immunization, or carriage. Because the patient’s HBsAg is negative, she is not the source of her husband’s infection. Full treatment for this patient has an efficacy of only 75% so follow-up testing is still needed.
As a member of the local emergency response management team you are asked about the treatment of nerve gas (e.g., sarin) poisoning. Which one of the following is most effective in reversing the symptoms of nerve gas toxicity? (check one)
A. Albuterol (Proventil, Ventolin) via inhalation
B. Ciprofloxacin (Cipro)
C. Atropine
D. Parenteral verapamil (Calan, Isoptin)
E. Parenteral corticosteroids
c
Nerve gas agents such as sarin resemble organophosphate insecticides and inactivate anticholinesterase, leading to the accumulation of ACh at nerve endings. Respiratory symptoms include rhinorrhea, bronchorrhea, bronchospasm, and respiratory muscle paralysis. GI symptoms include NVD. CNS symptoms include HA, vertigo, agitation, seizures, and coma. Exposed patients benefit from treatment with atropine, which competitively inhibits acetylcholine. Pralidoxine chloride and diazepam are also beneficial.
Although ß-agonists and corticosteroids are beneficial in the general treatment of bronchospasm, atropine is preferred in this situation. Verapamil and ciprofloxacin have no role in the treatment of nerve gas exposure.
A 50-year-old male presents with a 1-day history of fever and chest pain. The chest pain is worse when he is in a supine position and with deep inspiration, and improves when he leans forward. He has no shortness of breath and has never had this problem before. His vital signs are normal except for a temperature of 37.8°C (100.0°F). He has no other medical problems or allergies, and takes no medications. An EKG reveals widespread ST-segment elevation, upright T waves, and PR-segment depression. His troponin level is normal. An echocardiogram is pending.
Which one of the following would be the most appropriate treatment for this patient?
A. Aspirin
B. Prednisone
C. Heparin
D. Enoxaparin (Lovenox)
A
Acute pericarditis - A friction rub can be heard in up to 85% of patients with acute pericarditis. An ECHO is often performed to determine the type and amount of effusion. Conventional therapy for acute pericarditis includes NSAIDs, such as aspirin and ibuprofen. Recent studies demonstrate that adding colchicine to aspirin may be beneficial in reducing the persistence and recurrence of symptoms.
Patients with Wolff-Parkinson-White syndrome who have episodic symptomatic supraventricular tachycardia or atrial fibrillation benefit most from: (check one)
A. Episodic intravenous digoxin
B. Long-term oral digitalis
C. Episodic beta-blockers
D. Radiofrequency catheter ablation of bypass tracts
D
Radiofrequency catheter ablation of bypass tracts is possible in over 90% of patients and is safer and more cost effective than surgery, with a similar success rate.
IV and PO digoxin can shorten the refractory period of the accessory pathway, and increase the ventricular rate, causing ventricular fibrillation.
Beta-blockers will not control the ventricular response during atrial fibrillation when conduction proceeds over the bypass tract.
A 50-year-old female with a history of paroxysmal atrial fibrillation has been successfully treated for depression with sertraline (Zoloft). However, she has persistent insomnia, and a 10-day trial of zolpidem (Ambien) has yielded minimal improvement. The most appropriate addition to her current medication would be: (check one)
A. Trazodone (Desyrel) each evening
B. Lorazepam (Ativan) daily
C. Zaleplon (Sonata) at night
D. Amitriptyline (Elavil) at night
A
Trazodone has been found useful for its sedative and hypnotic effects, and is often used in combination with another antidepressant.
Benzodiazepines are not recommended for long-term use.
Zaleplon is more short-acting than zolpidem and therefore would not be more effective.
Amitriptyline could be used for its antidepressant and sedative effects, but its chronotropic side effects make it less preferable for someone with a disposition to cardiac arrhythmia.
A 35-year-old female is planning a second pregnancy. Her last pregnancy was complicated by placental abruption caused by a large fibroid tumor of the uterus, which is still present. Which one of the following would be the most appropriate treatment for the fibroid tumor? (check one)
A. Myomectomy
B. Myolysis with endometrial ablation
C. Uterine artery embolization
D. Observation
A
When pregnancy is desired, myomectomy offers the best chance for a successful pregnancy when prior pregnancies have been marked by fibroid-related complications.
Endometrial ablation eliminates fertility, and there is a lack of long-term data on fertility after uterine artery embolization.
Observation without treatment would not remove the risk for recurrent complications during subsequent pregnancies.
Which one of the following findings on examination of the head, oral cavity, and neck is associated with diabetes mellitus? (check one)
A. Parotid enlargement
B. Tooth erosion
C. Diffuse melanin pigmentation
D. Cobblestone oral mucosa
E. Painful oral ulcers
A
Sialadenosis, bilateral non-inflammatory enlargement of the parotid gland, is associated with diabetes mellitus. Periodontal bleeding and inflammation, candidiasis, and delayed wound healing also are associated with diabetes mellitus.
Tooth erosion can be an oral manifestation of GERD or bulimia.
Cobblestone oral mucosa is seen in Crohn’s disease.
Diffuse melanin pigmentation is an oral finding of Addison’s disease.
Painful oral ulcers occur in several conditions, including Behçet syndrome, aphthous ulcers, pemphigus, and pemphigoid.
A 45-year-old male presents with a 3-month history of hoarseness. He denies any other complaints and has not been ill recently. He is not on any medication, has no history of chronic medical problems, and does not smoke cigarettes or drink alcohol.
Which one of the following would be the most appropriate management of this patient?
A. Voice rest for 1 month
B. Laryngoscopy
C. A trial of a proton pump inhibitor
D. A trial of inhaled corticosteroids
E. Oral corticosteroids
B
Laryngoscopy should be performed to visualize the larynx and evaluate for vocal cord pathology in a patient whose hoarseness does not resolve within 3 months. If a serious condition is suspected for some other reason, laryngoscopy should be performed regardless of the duration of symptoms.
If there is a recent history of upper respiratory infection or vocal abuse, then it would be appropriate to recommend voice rest for 2 weeks. Laryngoscopy would then be indicated if the hoarseness did not improve or recurred after voice rest.
For patients with symptoms of gastroesophageal reflux, a trial of a proton pump inhibitor is recommended.
Inhaled corticosteroids, especially fluticasone, may cause hoarseness. Oral corticosteroids do not have a role in the management of hoarseness.
In women with polycystic ovary syndrome, the risk is increased the most for carcinoma of the?
A. Breast
B. Cervix
C. Colon
D. Endometrium
E. Ovary
D
Several disorders that are common in women with polycystic ovary syndrome are associated with an increased risk for endometrial carcinoma, including obesity, hyperinsulinemia, diabetes mellitus, anovulatory cycles, and high androgen levels.
A 52-year-old male presents for a routine physical examination. His laboratory results reveal an AST (SGOT) level of 124 U/L (N 10–40) and an ALT (SGPT) level of 36 U/L (N 10–55). His gamma-glutamyl transpeptidase (GGTP) level is also elevated. The most likely cause of this abnormality is? (check one)
A. Hepatitis
B. Hemochromatosis
C. Nonalcoholic fatty liver disease
D. Alcoholic liver disease
E. Statin-induced liver disease
D
An AST/ALT ratio >2 supports a diagnosis of alcoholic liver disease. Elevated (-glutamyl transpeptidase (GGTP) is also associated with alcohol abuse, especially in a patient with an AST/ALT ratio >2.
You are evaluating a 68-year-old male with obstructive urinary symptoms. Which one of the following medications may lead to falsely depressed levels of prostate-specific antigen (PSA)? (check one)
A. Terazosin (Hytrin)
B. Finasteride (Proscar)
C. Tamsulosin (Flomax)
D. Doxazosin (Cardura)
E. Lycopene
B
Finasteride has considerable efficacy in treating obstructive symptoms, but it unfortunately falsely depresses PSA levels. In patients taking finasteride, this can affect the evaluation for carcinoma of the prostate.
Finasteride can Fake the PSA levels
A 49-year-old white female comes to your office complaining of painful, cold finger tips which turn white when she is hanging out her laundry. While there is no approved treatment for this condition at this time, which one of the following drugs has been shown to be useful? (check one)
A. Propranolol (Inderal)
B. Nifedipine (Procardia)
C. Ergotamine/caffeine (Cafergot)
D. Methysergide (Sansert)
B
At present there is no approved treatment for Raynaud’s disease. However, patients with this disorder reportedly experience subjective symptomatic improvement with calcium channel antagonists, with nifedipine being the calcium channel blocker of choice.
ß-Blockers can produce arterial insufficiency of the Raynaud type, so propranolol and atenolol are contraindicated. Drugs such as ergotamine preparations and methysergide can produce cold sensitivity, and should therefore be avoided in patients with Raynaud’s disease.
Which one of the following is the recommended duration of thromboprophylaxis following total hip arthroplasty, starting from the day of surgery and including outpatient prophylaxis?
A. 7 days
B. 14 days
C. 35 days
D. 60 days
E. 90 days
C
For patients undergoing major orthopedic surgery, the American College of Chest Physicians recommends outpatient thromboprophylaxis for a duration of up to 35 days. Older recommendations for 10–14 days of prophylaxis were based on studies performed when this was the usual hospital stay. This is still recommended as the minimum length for prophylaxis, but a longer period of time is preferred.
A 24-year-old female who works at a day-care facility presents to your office to discuss ways to avoid getting “all the infections the kids get.” She plans to enroll her child in the facility. She is specifically concerned about diarrheal illnesses, and a friend has suggested the use of probiotics. (check one)
A. can lessen the severity and duration of infectious diarrhea
B. are recommended only for patients who are immunocompromised
C. have no known side effects
D. often interact with common prescription medications
E. are not appropriate for use in children
A
Probiotics are microorganisms with likely health benefits, based on recent randomized, controlled trials. Good evidence suggests that probiotics reduce the incidence, duration, and severity of antibiotic-associated and infectious diarrhea. Common side effects include flatulence and abdominal pain. Contraindications include short-gut syndromes and immunocompromised states. There are no known drug interactions, and these agents appear safe for all ages.
A 6-year-old white male visits your office with chief complaints of a recent onset of fever, bilateral knee and ankle pain, colicky abdominal pain, and rash. On examination, his temperature is 38.3 degrees C (101.0 degrees F), and there is a prominent palpable reddish-brown rash on the buttocks and thighs. There is pain on motion of his knees and ankles, and mild diffuse abdominal tenderness. The stool is positive for occult blood. Laboratory Findings Hemoglobin 11.0 g/dL (N 11.5-13.5) Hematocrit 33% (N 34-40) WBCs 14,500/mm3 (N 5500-15,000); 85% segs, 15% lymphs Platelets 345,000/mm3 (N 150,000-400,000) Prothrombin time 12 sec (N 11-15) Which one of the following is the most likely diagnosis? (check one)
A. Systemic onset juvenile rheumatoid arthritis
B. Rocky Mountain spotted fever
C. Henoch-Schonlein purpura
D. Disseminated anthrax
E. Acute iron ingestion
C
Henoch-Schonlein purpura typically follows an URI, and presents with low-grade fever, fatigue, arthralgia, colicky abdominal pain, and rash, which begins as pink maculopapules, progresses to petechiae or purpura, which are clinically palpable, and changes in color from red to dusty brown before fading. Arthritis, usually involving the knees and ankles, is present in two-thirds of cases, and GI tract involvement results in heme-positive stools in 50% of cases. Laboratory findings are not specific or diagnostic, and include indications of mild to moderate thrombocytosis, leukocytosis, and anemia, and an elevated ESR.
Treatment is typically symptomatic and supportive, although corticosteroids are indicated in the rare patient with life-threatening GI or CNS manifestations.
Systemic juvenile-onset rheumatoid arthritis usually presents with an evanescent salmon-pink rash.
Rocky Mountain spotted fever does not present with arthritis and the rash begins distally on the legs. Iron ingestion does not typically cause a rash, fever, or arthritis.
Disseminated anthrax does not present with a rash and joint symptoms
A 68-year-old female presents with recent poor oral intake, fatigue, and confusion. Osmotic demyelination syndrome (central pontine myelinolysis) and permanent neurologic deficits could result from overly rapid correction of which one of the following abnormalities?
A. Hyperglycemia
B. Hyperkalemia
C. Hypokalemia
D. Hypernatremia
E. Hyponatremia
E
Overly rapid correction of hyponatremia may cause osmotic demyelination syndrome aka central pontine myelinolysis. Signs and symptoms may include dysarthria, dysphagia, paresis, coma, and seizures. It is believed that brain volume shrinks because it cannot assimilate the new electrolytes fast enough and water is lost from the cells.
Rapid correction of hypernatremia that has been present for a short time is relatively safe.
Hyperkalemia is a life-threatening condition that should be corrected promptly.
Rapid correction of hypoglycemia is not an issue.
Overly rapid correction of hyperglycemia and subsequent cerebral edema is unusual and is primarily seen in children.
A mother brings her 10-year-old son to your office because he has recently experienced a flare-up of atopic dermatitis, including increased pruritus. Physical findings include increased erythema of the involved skin on the flexural surfaces of his arms and legs, with weeping eruptions located within areas of lichenification.
Which one of the following topical treatments for managing this episode is supported by the best available evidence? (check one)
A. Emollients
B. Pimecrolimus (Elidel)
C. Mupirocin (Bactroban)
D. Corticosteroids
E. Antihistamines
D
Emollients are a mainstay of chronic therapy for atopic dermatitis, but topical corticosteroids are the first-line treatment for flare-ups. Calcineurin inhibitors such as pimecrolimus are a second-line treatment for moderate to severe atopic dermatitis. Antibiotics are not useful in reducing flare-ups of atopic dermatitis unless there is clear evidence of a secondary infection. Neither topical nor oral antihistamines are recommended for routine treatment of atopic dermatitis because they are not effective in treating the associated pruritus.
A previously healthy 67-year-old male sees you for a routine health maintenance visit. During the physical examination you discover a harsh systolic murmur that is loudest over the second right intercostal space and radiates to the carotid arteries. The patient denies any symptoms of dyspnea, angina, syncope, or decreased exertional tolerance. An echocardiogram shows severe aortic stenosis, with an aortic valve area of 40 mm Hg, and an ejection fraction of 60%.
Which one of the following would be most appropriate at this point?
(check one)
A. Coronary angiography
B. Exercise stress testing
C. Treatment with prazosin (Minipress)
D. Referral for aortic valve replacement
E. Watchful waiting
E
Watchful waiting is recommended for most patients with asymptomatic aortic stenosis, including those with severe disease. This is because the surgical risk of aortic valve replacement outweighs the approximately 1% annual risk of sudden death in asymptomatic patients with aortic stenosis.
An 8-year-old male presents to your office 2 days after returning from a trip to Mexico with his family. He developed watery, nonbloody diarrhea on the day of departure. He has mild abdominal cramping, but no fever or vomiting. His mother had similar symptoms, which were milder and resolved with over-the-counter treatments.
Which one of the following would be most appropriate to treat this patient’s condition?
A. Metronidazole (Flagyl)
B. Ciprofloxacin (Cipro)
C. Azithromycin (Zithromax)
D. Mebendazole
E. Metoclopramide (Reglan)
C
Traveler’s diarrhea commonly occurs in travelers to Mexico and developing countries. It is usually caused by bacterial organisms such as E. coli, Campylobacter, Shigella, and Salmonella. Viral and parasitic organisms are less common causes, unless the diarrhea persists for 2 weeks. Appropriate medications include antidiarrheal agents such as loperamide, bismuth subsalicylate, and antibiotics. Azithromycin is generally effective and safe in children. Fluoroquinolones are effective in adults, but should not be used in an 8-year-old. Metronidazole, mebendazole, and metoclopramide would not be likely to successfully treat bacterial traveler’s diarrhera.
The parents of a 5-year-old male ask you about treating him for ADHD because of his hyperactivity at home and preschool. According to the newest guidelines, the most appropriate next step is to? (check one)
A. prescribe a very low dose of stimulant medication
B. explain to the parents that drug therapy for ADHD is not appropriate at this age
C. perform a dietary history focusing on the child’s sugar intake
D. ) explore the nature of his hyperactivity and whether there are coexisting behavioral problems
D
Stimulant medication can be prescribed for preschool children, but only after a thorough trial of behavior modification.
Foods and additives have never been shown to cause or aggravate ADHD.
Children with ADHD often have other behavioral problems such as depression or oppositional-defiant disorder.
You are evaluating a 25-year-old gravida 5 para 1 at 6 weeks estimated gestation. She has a history of three consecutive spontaneous miscarriages. Her workup has been negative except for a positive lupus anticoagulant on two occasions, separated by 6 weeks. You make the diagnosis of antiphospholipid antibody syndrome. She has no previous history of venous or arterial thrombosis. The best medical management at this time is: (check one)
A. Acetaminophen
B. Warfarin (Coumadin)
C. Prednisone
D. Aspirin and heparin combined
E. Progesterone
D
Antiphospholipid antibody syndrome in pregnancy is associated with an increased risk of thromboembolism, fetal loss, thrombocytopenia, and poor pregnancy outcome. Combination of aspirin and heparin is most effective for decreasing fetal loss. One study showed decreased fetal loss with a combination of corticosteroids and aspirin, but the results have not been reproduced in subsequent studies. In addition, the use of prednisone was associated with an increased risk of premature rupture of membranes, preterm delivery, fetal growth restriction, infection, preeclampsia, diabetes, osteopenia, and avascular necrosis.
Progesterone may be useful for recurrent spontaneous abortion related to a luteal phase defect, but has not been shown to be effective in preventing complications associated with antiphospholipid antibody syndrome.
Which one of the following metabolic abnormalities is most likely to be seen in patients with stage 4 kidney disease?
A. Hyperaldosteronism
B. Hyperparathyroidism
C. Hypothyroidism
D. Hypogonadism
E. Type 2 diabetes mellitus
B
Hyperparathyroidism is present in more than half of patients who have a GFR , and is independently associated with increased mortality and an increased prevalence of cardiovascular disease.
In patients with stage 4 chronic kidney disease, current guidelines recommend monitoring of serum calcium and phosphate levels every 3–6 months and bone-specific alkaline phosphatase activity every 6–12 months with the goal of normalizing these values.
The other metabolic abnormalities listed are less common than hyperparathyroidism.
A 2-week-old female is brought to the office for a well child visit. The physical examination is completely normal except for a clunking sensation and feeling of movement when adducting the hip and applying posterior pressure. Which one of the following would be the most appropriate next step? (check one)
A. Referral for orthopedic consultation
B. Reassurance that the problem resolves spontaneously in 90% of cases, and follow-up in 2 weeks
C. Triple diapering and follow-up in 2 weeks
D. A radiograph of the pelvis
A
Developmental dysplasia of the hip: subluxation, dislocation, or anatomic abnormalities.
Common in firstborns, females, breech presentations, oligohydramnios, and patients with a family history of developmental dysplasia.
Experts are divided with regard to whether hip subluxation can be merely observed during the newborn period, but if there is any question of a hip problem on examination by 2 weeks of age, the recommendation is to refer to a specialist for further testing and treatment. The current recommendation is to treat all children with closed reduction and immobilization in a Pavlik harness, with ultrasonography of the hip to ensure proper positioning, is the treatment of choice until 6 months of age.
Studies show that these problems disappear by 1 week of age in 60% of cases, and by 2 months of age in 90% of cases.
Triple diapering should not be used because it puts the hip joint in the wrong position and may aggravate the problem.
Plain radiographs may be helpful after 4-6 months of age, but prior to that time the ossification centers are too immature to be seen.
Because the condition can be difficult to diagnose, and can result in significant problems, the current recommendation is to treat all children with developmental dysplasia of the hip. Closed reduction and immobilization in a Pavlik harness, with ultrasonography of the hip to ensure proper positioning, is the treatment of choice until 6 months of age.
Which one of the following sleep problems in children is most likely to occur during the second half of the night? (check one)
A. Confusional arousals
B. Sleepwalking
C. Sleep terrors
D. Nightmares
D
Nightmares occur in the second half of the night, when REM sleep is most prominent.
Parasomnias, including sleepwalking, confusional arousal, and sleep terrors, are disorders of arousal from non-REM sleep. These are more common in children than adults because children spend more time in deep NREM sleep. Such disorders usually occur within 1-2 hours after sleep onset, and coincide with the transition from the first period of slow-wave sleep.
Which one of the following sonographic measurements is most accurate for estimating gestational age? (check one)
A. Amniotic sac size at 5 weeks of pregnancy
B. Crown-rump length at 10 weeks of pregnancy
C. Femur length at 16 weeks of pregnancy
D. Biparietal diameter at 20 weeks of pregnancy
E. Abdominal circumference at 24 weeks of pregnancy
B
Estimation of gestational age by US is most accurate early in the first trimester and begins to decline by 22 weeks gestation.
Crown-rump length is typically used to estimate gestational age before 13 weeks gestation (1st trimester)
After 11 weeks gestation, biparietal diameter, femur length, head circumference, and abdominal circumference are used (second + third trimester)
Surgical management for an acute midshaft clavicle fracture would be appropriate in which one of the following? (check one)
A. An 11-year-old male with a comminuted fracture
B. A 15-year-old female with a ½-cm displaced fracture
C. A 30-year-old male with a ½-cm displaced fracture
D. A 40-year-old male with a nondisplaced fracture
E. A 50-year-old female with a comminuted fracture
comminuted fracture = fracture that results in more than 2 separate bone component
E
Midshaft clavicle fractures are usually treated nonoperatively, but have a higher risk of nonunion. Risk factors for nonunion include female gender, comminuted fractures, or displacement, clavicle shortening, advanced age, and greater extent of initial trauma.
These fractures in children heal extremely well, even if displaced or comminuted, because of periosteal regenerative potential.
Which one of the following is the recommended duration of dual antiplatelet therapy after placement of a drug-eluting coronary artery stent? (check one)
A. 1 week
B. 1 month
C. 2 months
D. 3 months
E. 1 year
E
The recommended duration of DUAL antiplatelet therapy following placement of a drug-eluting coronary artery stent is 1 year. The recommended dosages are aspirin, 162–325 mg + clopidogrel, 75 mg OR prasugrel, 10 mg. Ticlopidine is an option for patients who do not tolerate clopidogrel or prasugrel.
The minimum recommended duration of dual antiplatelet therapy is
- 1 month with bare-metal stents
- 3 months with sirolimus-eluting stents
- 6 months with other drug-eluting stents.
You have just diagnosed mild persistent asthma in a 13-year-old African-American female. Along with patient education, your initial medical management should be: (check one)
A. a short-acting inhaled β-agonist to be used only as needed
B. a long-acting inhaled β-agonist daily
C. a low-dose inhaled corticosteroid daily, along with a short-acting inhaled β-agonist as needed
D. a low-dose inhaled corticosteroid daily, along with a long-acting inhaled β-agonist daily
E. montelukast (Singulair) daily
C
Inhaled corticosteroids improve asthma control in adults/children more effectively than any other single long-term controller medication, and all patients should also receive a prescription for a short-acting β-agonist.
A 26-year-old female presents with a 1-year history of recurring abdominal pain associated with intermittent diarrhea, 5-7 days per month. Her pain improves with defecation. There has been no blood in her stool and no weight loss. Laboratory findings are normal, including a CBC, chemistry profile, TSH level, and antibodies for celiac disease. Which one of the following would be most appropriate at this point? (check one)
A. Colonoscopy
B. An upper GI series with small-bowel follow-through
C. Abdominal CT with contrast
D. A gluten-free diet
E. Loperamide (Imodium)
E
This patient has IBS and meets the Rome criteria by having 3 days per month of abdominal pain for the past 3 months, a change in the frequency of stool, and improvement with defecation. According to current clinical guidelines IBS can be diagnosed by history, physical examination, and routine laboratory testing, as long as there are no warning signs. Warning signs include rectal bleeding, anemia, weight loss, fever, a family history of colon cancer, onset of symptoms after age 50, and a major change in symptoms.
Colonoscopy, CT, and GI contrast studies are not indicated. A gluten-free diet would not be indicated since the antibody tests for celiac disease are negative. Antidiarrheal agents such as loperamide are generally safe and effective in the management of diarrheal symptoms in IBS.
A 70-year-old white male has a slowly enlarging, asymptomatic abdominal aortic aneurysm. You should usually recommend surgical intervention when the diameter of the aneurysm approaches: (check one)
A. 3.5 cm
B. 4.5 cm
C. 5.5 cm
D. 6.5 cm
E. 7.5 cm
C
An asymptomatic 68-year-old male sees you for a health maintenance visit. He is a former cigarette smoker, but quit 20 years ago.
According to the U.S. Preventive Services Task Force, evidence shows that the potential benefit exceeds the risk for which one of the following screening tests in this patient? (check one)
A. A chest radiograph
B. Abdominal ultrasonography
C. Ophthalmic tonometry
D. A prostate-specific antigen level
E. An EKG
B
USPSTF recommends one-time screening for AAA by abdominal US in men aged 65–75 who have ever smoked.
USPSTF found good evidence that screening these patients for AAA and surgical repair of large AAAs (≥5.5 cm) leads to decreased AAA-specific mortality.
A 35-year-old white male who has had diabetes mellitus for 20 years begins having episodes of hypoglycemia. He was previously stable and well controlled and has not recently changed his diet or insulin regimen.
Which one of the following is the most likely cause of the hypoglycemia?
A. Spontaneous improvement of β-cell function
B. Renal disease
C. Reduced physical activity
D. Insulin antibodies
B
The most common cause of hypoglycemia in a previously stable, well-controlled diabetic patient who has not changed his or her diet or insulin dosage is diabetic renal disease, resulting in spillage of glucose into the urine
A reduction in physical activity or the appearance of insulin antibodies (unlikely after 20 years of therapy) would increase insulin requirements and produce hyperglycemia. Spontaneous improvement β -cell function after 20 years would be very rare.
The use of automated external defibrillators by lay persons in out-of-hospital settings: (check one)
A. Has been frustrated by liability concerns
B. Has been hampered by an unwillingness to place the devices in public areas
C. Has been shown to contribute to significant gains in full neurologic and functional recovery
D. Has been eclipsed by the widespread use of internal cardiac defibrillators in high-risk patients
C
The use of automated external defibrillators (AEDs) by lay persons, trained and otherwise, has been quite successful, with up to 40% of those treated recovering full neurologic and functional capacity.
The mother of a 16-year-old male brings him to your office stating that she wants to find out if he has Crohn’s disease. She says that both she and the child’s aunt were diagnosed with this condition by another physician with “blood tests.” The son tells you that for the past several years his stool is intermittently loose and he has up to three bowel movements in a day. He says he does not have fever, pain, hematochezia, weight loss, or any extraintestinal symptoms. A physical examination is normal.
Which one of the following would be the most appropriate preliminary testing? (check one)
A. A plain radiograph of the abdomen
B. CT of the abdomen and pelvis
C. An inflammatory bowel disease serologic panel
D. Colonoscopy with a biopsy
E. A CBC, serum chemistry panel, and erythrocyte sedimentation rate
E
Diagnosis of inflammatory bowel disease (IBD) can be elusive but relies primarily on the patient history, laboratory findings, and endoscopy (or double-contrast radiographs if endoscopy is not available).
The preliminary evaluation include a WBC count, platelet count, potassium level, and erythrocyte sedimentation rate.
Endoscopy is reserved for patients with more severe symptoms or in whom preliminary testing shows the potential for significant inflammation.
Over the past year, a 32-year-old white female has experienced increasing hair growth on her chin and chest, acne, and irregular menstrual periods. She takes no medications. Which one of the following would be the most appropriate course of action at this point?
A. Empiric treatment with metformin (Glucophage)
B. CT of the adrenal glands
C. Laboratory testing
D. Brain MRI
E. Pelvic ultrasonography
C
Testing for androgen excess is indicated in the young woman with an acute onset of hirsutism or when it is associated with menstrual irregularity, infertility, central obesity, acanthosis nigricans, or clitoromegaly.
Elevated early morning total testosterone is most often associated with polycystic ovary syndrome. Testing to r/o other etiologies would include:
- pregnancy testing if the patient has amenorrhea
- serum prolactin level to exclude hyperprolactinemia
- DHEA-S and early morning 17-hydroxyprogesterone to detect adrenal hyperandrogenism and congenital adrenal hyperplasia
- Assessment for Cushing syndrome, thyroid disease, or acromegaly is appropriate if associated signs or symptoms are present
- Pelvic US to evaluate for ovarian neoplasm or polycystic ovaries, although PCOS is a clinical diagnosis and US has a low sensitivity.
A 3-year-old male is brought to the emergency department by his parents, who report seeing him swallow a handful of adult ibuprofen tablets 20 minutes ago. Which one of the following would be the most appropriate initial management of this patient? (check one)
A. Oral ipecac
B. Oral activated charcoal
C. Gastric lavage
D. Whole-bowel irrigation
E. Close observation
B
A single dose of activated charcoal is the decontamination treatment of choice for most medication ingestions. It should be used within 1 hour of ingestion of a potentially toxic amount of medication.
Gastric lavage, cathartics, or whole bowel irrigation is best for ingestion of medications that are poorly absorbed by activated charcoal (iron, lithium) or medications in sustained-release or enteric-coated formulations.
Ipecac has no role in home use or in the health care setting
A 64-year-old white male presents to the emergency department with a 48-hour history of left lower quadrant pain. After a thorough history and a physical examination you conclude that the patient has diverticulitis. The patient is allergic to metronidazole (Flagyl). You recommend a clear-liquid diet, a follow-up visit with his primary care physician in 48 hours, and treatment with:
A. amoxicillin
B. amoxicillin/clavulanate (Augmentin)
C. ciprofloxacin (Cipro)
D. doxycycline
E. azithromycin (Zithromax)
B
An accepted regimen for outpatient treatment of diverticulitis is amoxicillin/clavulanate, 875 mg every 12 hours. The other regimens are not optimal treatments because they do not include anaerobic coverage.
A 75-year-old male has not seen a physician in 25 years and presents with advanced Parkinson’s disease. The best initial treatment would be: (check one)
A. Referral to a neurosurgeon for thalamotomy
B. Amantadine (Symmetrel)
C. Benztropine (Cogentin)
D. Pramipexole (Mirapex)
E. Carbidopa/levodopa (Sinemet)
E
Anticholinergics benztropine and amantadine may provide some improvement of symptoms, but the effects wane within a few months and is not a good option in this patient with advanced disease.
Dopamine agonists (Pramipexole (Mirapex)) provide some improvement in motor complications, but are mainly used to delay the introduction of levodopa in younger patients, to avoid levodopa-related adverse reactions.
Carbidopa/levodopa is better for initial therapy in older patients, and those who present with more severe symptoms. Slow-release versions may decrease motor fluctuations.
Stereotactic thalamotomy is used to ameliorate tremors that have become disabling. This procedure has been replaced by other surgical options such as pallidotomy and high-frequency, deep-brain stimulation of specific nuclei.
A 26-year-old female presents with symptoms of anhedonia and anxiousness. Your evaluation leads to a diagnosis of major depressive disorder. The patient consents to medical treatment and counseling, but she is engaged to be married in 2 months and is concerned that antidepressants may lower her libido even further.
Which one of the following would be best for reducing the likelihood of sexual dysfunction?
A. Bupropion (Wellbutrin)
B. Paroxetine (Paxil)
C. Fluoxetine (Prozac)
D. Sertraline (Zoloft)
A
Paroxetine has been found to cause higher rates of sexual dysfunction than bupropion, fluoxetine, and sertraline. Bupropion has been found to have significantly lower rates of adverse effects on sexual function than fluoxetine or sertraline.
Which one of the following medications used in the treatment of osteoporosis can also be used to treat the pain associated with acute and chronic vertebral compression fractures?
A. Calcitonin-salmon (Miacalcin)
B. Raloxifene (Evista)
C. Risedronate (Actonel)
D. Teriparatide (Forteo)
E. Zoledronic acid (Reclast)
A
While all of the medications listed can be used to treat osteoporosis, only calcitonin-salmon is useful in the management of pain associated with acute or chronic vertebral fractures. Calcitonin is an antiresorptive agent that has been shown to decrease the risk of vertebral fractures, but it is not considered a first-line treatment for osteoporosis because there are more effective agents. However, it does have modest analgesic properties that make it useful in the treatment of the pain associated with vertebral fractures.
A 41-year-old male trips on a curb while running, sustaining an inversion ankle injury. According to the Ottawa ankle rules, which one of the following would be an indication for radiographic evaluation? (check one)
A. Tenderness at the anterior talofibular ligament
B. Point tenderness over the cuboid
C. Inability to take four steps either immediately after the injury or while in your office
D. Bony tenderness at the anterior aspect of the distal tibia
E. Point tenderness over the base of the fourth metatarsal
C
The Ottawa ankle rules have been designed and validated to reduce unnecessary radiographs. Radiographs should be obtained for all patients with an acute ankle injury who meet any of the following criteria:
- inability to take four steps, either immediately after the injury or when being evaluated
- localized tenderness of the navicular bone or the base of the fifth metatarsal
- localized tenderness at the posterior edge or tip of either malleolus.
Which one of the following sleep disorders is in the general class of circadian sleep disorders and may respond to bright-light therapy? (check one)
A. Shift-work insomnia
B. Alcohol-dependent sleep disorder
C. Inadequate sleep hygiene
D. Sleep-related myoclonus
A
Shift-work insomnia is the only circadian sleep disorder listed. It may respond to bright-light therapy.
In assessing the nutritional status of an infant it is useful to know that birth weight is expected to be regained within: (check one)
A. 5 days
B. 14 days
C. 21 days
D. 28 days
B
A helpful guideline for assessing normal growth in the very young infant is that birth weight should be regained within 14 days
A 55-year-old female has a 2-year history of a slowly progressive bilateral tremor. The tremor interferes with her writing and eating. She has recently noted head bobbing and a change in her voice.
Which one of the following would be an appropriate first-line medication for this problem? (check one)
A. Levetiracetam (Keppra)
B. Olanzapine (Zyprexa)
C. Alprazolam (Xanax)
D. Carbidopa/levodopa (Sinemet)
E. Propranolol
E
Primidone and propranolol are the first-line drugs for essential tremor. Alprazolam is considered to be possibly effective. The tremor described is not due to Parkinson’s disease and would not respond to carbidopa/levodopa. Levetiracetam is not effective. There is not enough evidence to recommend for or against the use of olanzapine.
A 62-year-old male underwent percutaneous coronary intervention and placement of two stents for a myocardial infarction yesterday. He is currently taking simvastatin (Zocor), aspirin, lisinopril (Prinivil, Zestril), and hydrochlorothiazide. His last LDL-cholesterol level was 70 mg/dL and his blood pressure is 130/80 mm Hg.
Which one of the following additions to his current regimen would be most appropriate at this time?
A. Amlodipine (Norvasc)
B. Diltiazem (Cardizem)
C. Verapamil (Calan, Verelan)
D. Metoprolol (Lopressor, Toprol-XL)
E. No changes
D
β-Blockers are first-line antihypertensive medications for patients with coronary artery disease (CAD) and have been shown to reduce the risk of death by 23% at 2 years. They should also be given to normotensive patients with CAD if tolerated. Cardioselective (β1) β-blockers such as metoprolol and atenolol are preferred, as they cause fewer adverse effects.
When treating acute adult asthma in the emergency department, using a metered-dose inhaler (MDI) with a spacer has been shown to result in which one of the following, compared to use of a nebulizer? (check one)
A. Higher hospitalization rates
B. Shorter stays in the emergency department
C. Higher relapse rates
D. Less improvement in peak-flow rates
E. Increases in the total dose of albuterol
B
Compared to nebulizers, MDIs with spacers have been shown to lower pulse rates, provide greater improvement in peak-flow rates, lead to greater improvement in arterial blood gases, and decrease required albuterol doses. They have also been shown to lower costs, shorten emergency department stays, and significantly lower relapse rates at 2 and 3 weeks compared to nebulizers. There is no difference in hospital admission rates.
A 2-year-old male is brought in for an initial office visit. He just moved to your community to live with foster parents. On examination, you note a thin upper lip, a smooth philtrum, a flat nasal bridge, small palpebral fissures, a curved fifth finger (clinodactyly), and a widened upper palmar crease that ends between the second and third fingers.
These findings suggest which one of the following? (check one)
A. Trisomy 21 (Down syndrome)
B. Marfan syndrome
C. Oligohydramnios sequence (Potter syndrome)
D. Fetal alcohol syndrome
E. Prader-Willi syndrome
D
Fetal alcohol syndrome - thin upper lip, a smooth philtrum, and a flat nasal bridge; clinodactyly (curved fifth finger towards the adjacent fourth finger); prenatal and postnatal growth retardation; and functional or structural CNS abnormalities.
Down syndrome - hypotonia, a flat face, upward and slanted palpebral fissures and epicanthic folds, and speckled irises (Brushfield spots); varying degrees of mental and growth retardation; dysplasia of the pelvis; cardiac malformations; a simian crease; short, broad hands; hypoplasia of the middle phalanx of the 5th finger; and a high, arched palate.
Marfan syndrome - pectus carinatum or pectus excavatum, an arm span to height ratio >1.05, a positive wrist and thumb sign, limited elbow extension, pes planus, and aortic ascendens dilatation with or without aortic regurgitation.
Potter syndrome - bilateral renal agenesis that leads to death shortly after birth; separated eyes with epicanthic folds, low-set ears, a broad and flat nose, a receding chin, and limb anomalies.
Prader-Willi syndrome - severe hypotonia at birth, obesity, short stature (responsive to growth hormone), small hands and feet, hypogonadism, and mental retardation.
A 14-year-old female sees you for follow-up after hypercalcemia is found on a chemistry profile obtained during a 5-day episode of vomiting and diarrhea. She is now asymptomatic, but her serum calcium level at this visit is 11.0 mg/dL (N 8.5–10.5). Her aunt underwent unsuccessful parathyroid surgery for hypercalcemia a few years ago.
Which one of the following laboratory findings would suggest a diagnosis other than primary hyperparathyroidism?
A. Low 24-hour urine calcium
B. Decreased serum phosphate
C. High-normal to increased serum chloride
D. Elevated alkaline phosphatase
E. Elevated parathyroid hormone
A
Low urine calcium levels (24 hr) or a low urine Ca:Cr ratio suggest familial hypocalciuric hypercalcemia; not hyperparathyroidism!! Awareness of this condition is important to avoid unnecessary surgery.
The PTH level may be mildly elevated. PTH is elevated in hyperparathyroidism. Serum chloride tends to be high normal or mildly elevated. Alkaline phosphatase may be elevated in more severe cases, while serum phosphate levels tend to be low.
Which one of the following is associated with vacuum-assisted delivery? (check one)
A. Lower fetal risk than with forceps delivery
B. More maternal soft-tissue trauma than forceps delivery
C. A reduced likelihood of severe perineal laceration compared to spontaneous delivery
D. An increased incidence of shoulder dystocia
D
Vacuum-assisted delivery is associated with
- higher rates of neonatal cephalhematoma and retinal hemorrhage compared with forceps delivery
- less maternal soft-tissue trauma when compared to forceps delivery
- increased likelihood of a severe perineal laceration without episiotomy; even higher risks with episiotomy.
- shoulder dystocia is more common with vacuum-assisted delivery than with forceps delivery
- increased likelihood of a severe perineal laceration is increased in women who have vacuum-assisted delivery without episiotomy compared to women wiht spontaneous vaginal delivery
An 85-year-old male is admitted to a nursing home due to weakness, debility, and limitation of activities of daily living (ADLs) after being hospitalized for acute community-acquired pneumonia. He previously lived with his wife independently and his goal is to return home when he is strong enough. He has a history of coronary artery disease, type 2 diabetes mellitus controlled with diet, hypertension, and chronic diastolic heart failure, but he has no symptoms related to these chronic problems. His appetite is poor and he has lost a significant amount of weight. His admission diet order from the hospital was a cardiac diet. Which one of the following would be the most appropriate diet for this patient?
A. A regular diet
B. An American Heart Association diet
C. A diet with no added salt
D. An 1800-calorie/day American Diabetes Association diet
E. A diet with no concentrated sweets
A
This patient should be provided with a regular diet, which may promote weight gain in nursing-home residents with unintentional weight loss. Malnutrition and unintentional weight loss are significant problems in nursing-home residents and lead to multiple complications, including pressure ulcers and infections.
The American Dietetic Association recommends liberalizing diets to improve nutritional status and quality of life in older adults. A small study demonstrated equivalent glycemic control in nursing-home residents who ate a regular diet compared to those who ate a restricted American Diabetes Association diet. Low-salt and low-cholesterol diets are unpalatable and are often associated with protein-energy malnutrition and postural hypotension in older persons. Special diets should be avoided whenever possible in nursing-home patients.
A patient is sent to you by his employer after falling down some steps and twisting his ankle and foot. Which one of the following would be the most appropriate reason to obtain foot or ankle radiographs? (check one)
A. Notable swelling and discoloration over the anterior talofibular ligament
B. A complaint of marked pain with weight bearing as he walks into the examining room
C. Pain in the maleolar zone and bone tenderness of the posterior medial malleolus
D. The absence of passive plantar foot flexion when the calf is squeezed (Thompson test)
C
Ottawa rules: ankle radiograph series is required only if there is
- pain in the malleolar zone and bone tenderness of either the distal 6 cm of the posterior edge or the tip of either the lateral malleolus or the medial malleolus.
- Inability to bear weight for four steps, both immediately after the injury and in the ED
Foot radiographs are required only if there is
- pain in the midfoot zone and bone tenderness at the base of the 5th metatarsal or the navicular
- inability to bear weight both immediately after the injury and in the ED
A 25-year-old female has an annular rash on the dorsal surface of both hands. The rash does not respond to initial treatment with an antifungal medication, and a biopsy reveals granuloma annulare.
Which one of the following would be the most appropriate advice for this patient?
A. Allow the rash to resolve without further treatment
B. Cover the rash because it is contagious
C. Treat the rash with systemic corticosteroids
D. Treat the rash with a stronger antifungal medication
A
Granuloma annulare is a self-limited condition. It is not contagious, and therefore would not need to be covered to prevent transmission. Treatments may include injected or topical corticosteroids, but oral corticosteroids have not been specifically recommended. It may be necessary to refer the patient to a dermatologist because many of the potential treatments can have serious side effects.
During a routine prenatal visit, a patient at 28 weeks gestation describes a worsening pain in her lower back and pelvic area. She is averse to analgesics but is eager to try exercise to relieve the pain. Additional patient history and an examination confirm that the pain is not due to underlying medical problems.
Which one of the following would be the most appropriate exercise prescription for this patient?
A. Isometric exercise
B. Concentric exercise
C. Core stability exercise
D. Closed kinetic chain exercise
E. Isotonic exercise
C
The most appropriate exercises for pregnancy-related pelvic pain and low back pain target the low back, trunk, and abdominal muscles to increase core stability. Examples of such exercises include Pilates, back extension exercises, and abdominal crunches.Isometric and isotonic exercises work muscle groups against either an external force or opposing muscle groups, and are best suited for the development of muscle tone, strength, and conditioning in the extremities. Likewise, concentric and closed kinetic chain exercises involve working muscles against resistance, and are best suited for rehabilitating and strengthening the extremities.
Typically, a high-grade squamous intraepithelial lesion (HSIL) of the cervix is treated with ablation or excision. In which one of the following can treatment be deferred?
A. Adolescents
B. Patients attempting to conceive
C. Patients with a history of three previous normal Papanicolaou smears
D. Patients with a negative DNA test for HPV
E. Patients over the age of 70
A
Patients attempting to conceive - not candidates for conservative management of cervical dysplasia, because treatment of progressive disease during pregnancy may be harmful. When possible, the problem should be resolved before conception.
Patients who have had 3 consecutive normal Paps - candidates for lengthened screening intervals. However, once a problem is found, they should be managed the same as other cases.
A negative test for HPV - used to assess risk of patients with atypical squamous cells of undetermined significance (ASC-US) or a low-grade squamous intraepithelial lesion (LSIL); it does not change the management of patients with a high-grade intraepithelial lesion (HSIL).
HPV infection is common and transient in most young women in their first few years of sexual activity. With careful follow-up, they can be observed rather than treated for HSIL.
Patients over 70 years of age no longer require screening if they have a long history of normal Pap smears, but when an abnormality is found it should be treated.
A 45-year-old female with no significant past medical history presents to your office with 2 weeks of worsening pain in her right arm. For the past 2 months she has worked on a plastics manufacturing assembly line. A physical examination reveals no swelling and a normal range of motion. She has normal strength in the upper extremity but she experiences increased pain with extension of her right wrist against resistance. Palpation reveals marked tenderness over the lateral epicondyle of the right arm.
Which one of the following is most likely to improve the patient’s long-term outcome?
(check one)
A. Physical therapy
B. Regular physical activity using her hands and arms
C. Use of an inelastic, nonarticular proximal forearm strap
D. Modifying her work routines
D
This patient has lateral epicondylitis aka tennis elbow, which is an overuse tendinopathy of the common extensor tendon origin of the lateral elbow.
Conservative care that includes offloading the involved tendons is the key to improving outcomes at 1 year, which would mean modifying this patient’s work.
PT can improve pain and function in the short term, but has not been shown to improve long-term outcomes at 1 year in randomized trials.
The evidence is weaker for bracing, with some studies showing improved pain and function at 3–6 weeks.
Recent randomized, controlled trials have made it clear that while corticosteroid injections reduce acute pain for up to 6 weeks, their use increases rates of poor long-term outcomes
Which one of the following is true regarding the treatment of generalized anxiety disorder? (check one)
A. Cognitive-behavioral therapy has been shown to be at least as effective as pharmacologic therapy
B. Buspirone (BuSpar) is as effective as SSRI therapy for patients with comorbid depression
C. Benzodiazepines are no more effective than placebo
D. Duloxetine (Cymbalta) is no more effective than placebo
E. Escitalopram (Lexapro) is no more effective than placebo
A
Cognitive-behavioral therapy has been shown to be at least as effective as medication for treatment of GAD, but with less attrition and more durable effects.
Many SSRIs and SNRIs have proven effective for GAD in clinical trials, but only paroxetine, escitalopram, duloxetine, and venlafaxine are approved by the FDA for this indication.
Benzodiazepines have been widely used because of their rapid onset of action and proven effectiveness in managing GAD symptoms.
SSRI or SNRI therapy is more beneficial than benzodiazepine or buspirone therapy for patients with GAD and comorbid depression.
Children of an elderly man who suffers from Alzheimer’s disease are bothered by his wandering and pacing behaviors. You have started treatment with a cholinesterase inhibitor, but the behavior persists. They ask you to prescribe additional drug therapy. You would recommend which one of the following? (check one)
A. No additional drug therapy
B. Risperidone (Risperdal)
C. Citalopram (Celexa)
D. Lorazepam (Ativan)
E. Valproic acid (Depakote)
A
Behavioral symptoms such as agitation and wandering become common as Alzheimer’s disease progresses. Cholinesterase inhibitors may improve some of these symptoms.
Atypical antipsychotics can help control problematic delusions, hallucinations, severe psychomotor agitation, and combativeness.
Typical antipsychotics help control these same problems, but are used more as second-line therapy in those who do not respond to atypical agents.
Mood-stabilizing drugs can help control these symptoms as well, and may also be useful alternatives to antipsychotic agents for controlling severe agitated, repetitive, and combative behaviors.
Benzodiazepines are used to manage insomnia, anxiety and agitation. Some behaviors, such as wandering and pacing, are not amenable to drug therapy.
A full-term newborn, born 72 hours ago, is noted to be jaundiced. The pregnancy was uneventful and the delivery uncomplicated. The mother has type A-positive blood and the child has type O-positive. The child is breastfed and has lost 9 ounces from a birth weight of 8 lb. He is feeding for 20 minutes every 4 hours, and except for being icteric, has a normal examination. Laboratory evaluation reveals a total serum bilirubin level of 16 mg/dL (N 1.4–8.7), with a conjugated bilirubin level of 1.0 mg/dL. His hemoglobin level is 17.8 g/dL (N 13.4–19.8), his hematocrit is 55% (N 41–65), and his reticulocyte count is 3% (N 3–7). Appropriate management would include: (check one)
A. Phototherapy
B. Exchange transfusion
C. Blood cultures and antibiotic therapy
D. Dextrose and water supplementation
E. A recommendation to increase feedings to 10 times a day
E
Hyperbilirubinemia - phototherapy should be initiated when the bilirubin level is
- > 15 mg/dL for infants at age 29–48 hours old
- at 18 mg/dL for infants 49–72 hours old
- at 20 mg/dL in infants older than 72 hours.
Generally, this problem is not considered pathologic unless it presents during the first hours after birth and the total serum bilirubin rises by > 5 mg/dL/day or is > 17 mg/dL, or if the infant has signs or symptoms suggestive of a serious underlying illness such as sepsis.
Physiologic jaundice follows a pattern, with the bilirubin level peaking on the third or fourth day of life and then declining over the first week after birth. Infants with multiple risk factors may develop an exaggerated form of physiologic jaundice, with the total bilirubin level rising as high as 17 mg/dL. Breastfed infants are 6x more likely to develop physiologic jaundice compared to formula-fed infants because of relative caloric deprivation in the first few days of life. For breastfed newborns who have an early onset of hyperbilirubinemia, the frequency of feeding should be increased to more than 10 times per day. If the newborn has a decrease in weight gain, delayed stooling, and continued poor intake, then formula supplementation may be necessary. Breastfeeding should be continued to maintain breast milk production. Supplemental water or dextrose and water should not be given, as this can decrease breast milk production and may place the infant at risk for iatrogenic hyponatremia
Which one of the following tests is most specific for diagnosing rheumatoid arthritis? (check one)
A. Anti-cyclic citrullinated peptide (anti-CCP) antibody
B. Antinuclear antibody
C. Erythrocyte sedimentation rate
D. Serum complement levels
E. Anti-Sm antibody
A
RA is primarily a clinical diagnosis and no single laboratory test is considered definitively diagnostic. Anti-cyclic citrullinated peptide (anti-CCP) antibody is more specific than rheumatoid factor (RF), and may predict erosive disease more accurately.
Antinuclear antibody has limited usefulness for the diagnosis of rheumatoid arthritis.
Anti-Sm antibody is useful to help diagnose systemic lupus erythematosus.
Nonspecific changes in complement levels are seen in many rheumatologic disorders.
The erythrocyte sedimentation rate is useful in monitoring disease activity and the course of rheumatoid arthritis, but is not specific.
Which one of the following platelet counts is the threshold for prophylactic platelet transfusion in most patients? (check one)
A. 10,000/μL
B. 25,000/μL
C. 40,000/μL
D. 50,000/μL
E. 100,000/μL
A
The threshold for prophylactic platelet transfusion is 10,000/μL. Platelet transfusion decreases the risk of spontaneous bleeding in such patients. A count below 50,000/μL is an indication for platelet transfusion in patients undergoing an invasive procedure.
Which one of the following organisms is the most common cause of cutaneous infections associated with intertrigo? (check one)
A. Candida albicans
B. Pseudomonas aeruginosa
C. Staphylococcus aureus
D. Group A β-hemolytic Streptococcus
E. Trichophyton mentagrophytes
A
Intertrigo is skin inflammation caused by skin-on-skin friction. It is facilitated by moisture trapped in deep skinfolds where air circulation is limited. When intertrigo does not respond to usual conservative measures, including keeping the skin clean and dry, evaluation for infection is recommended. A Wood’s light examination, KOH preparation, and exudate culture can assist in identifying causative organisms.
The moist, damaged skin associated with intertrigo is a fertile breeding ground for various microorganisms; with Candida the most common one.
In the interdigital spaces dermatophytes (e.g., Trichophyton rubrum, Trichophyton mentagrophytes, Epidermophyton floccosum) are more common.
S. aureus may present alone or with group A β-hemolytic Streptococcus.
Pseudomonas aeruginosa, Proteus mirabilis, or Proteus vulgaris also may occur alone or simultaneously.
An asymptomatic 3-year-old male presents for a routine check-up. On examination you notice a systolic heart murmur. It is heard best in the lower precordium and has a low, short tone similar to a plucked string or kazoo. It does not radiate to the axillae or the back and seems to decrease with inspiration. The remainder of the examination is normal. Which one of the following is the most likely diagnosis? (check one)
A. Eisenmenger’s syndrome
B. Mitral stenosis
C. Peripheral pulmonic stenosis
D. Still’s murmur
E. Venous hum
D
The cause of Still’s murmur is unknown, but it may be due to vibrations in the chordae tendinae, semilunar valves, or ventricular wall. A venous hum consists of a continuous low-pitched murmur caused by the collapse of the jugular veins and their subsequent fluttering, and it worsens with inspiration or diastole. The murmur of physiologic peripheral pulmonic stenosis (PPPS) is caused by physiologic changes in the newborns pulmonary vessels. PPPS is a systolic murmur heard loudest in the axillae bilaterally that usually disappears by 9 months of age. Mitral stenosis causes a diastolic murmur, and Eisenmenger’s syndrome involves multiple abnormalities of the heart that cause significant signs and symptoms, including shortness of breath, cyanosis, and organomegaly, which should become apparent from a routine history and examination.
A 55-year-old female who has hypertension, hyperlipidemia, and osteoarthritis of the knees develops acute gout and is found to have hyperuricemia. Discontinuation of which one of the following medications may improve her hyperuricemia? (check one)
A. Hydrochlorothiazide
B. Losartan (Cozaar)
C. Metoprolol (Lopressor)
D. Simvastatin (Zocor)
E. Acetaminophen
A
Diuretics such as hydrochlorothiazide are known to increase serum uric acid levels, but losartan has been shown to decrease uric acid. Metoprolol, simvastatin, and acetaminophen have no specific effect on serum uric acid levels.
A 20-year-old female is seen for follow-up 6 weeks after delivery. Her pregnancy was complicated by preeclampsia. Her examination is unremarkable. This patient will be at increased risk for which one of the following in midlife? (check one)
A. Breast cancer
B. Diabetes mellitus
C. Hypothyroidism
D. Kidney disease
E. Hypertension
E
Preeclampsia - is manifested as HTN, proteinuria, edema, and rapid weight gain after 20 weeks gestation. Very young mothers and those over age 35 have a higher risk.
Patients who have had preeclampsia have a 4-fold increased risk of hypertension and a 2-fold increased risk of ischemic heart disease, stroke, and venous thromboembolism.
A 13-year-old female is brought to your office for evaluation of school difficulties and depressed mood. Her mother and older sister have both been diagnosed with depression. After a thorough history and physical examination, you diagnose major depressive disorder. You arrange for the patient to receive cognitive-behavioral therapy, but after 6 weeks her condition is only minimally improved.
Which one of the following medications would be appropriate to add to this patient’s treatment plan at this point?
A. Fluoxetine (Prozac)
B. Imipramine (Tofranil)
C. Lithium
D. Venlafaxine
A
CBT and interpersonal therapy are two modalities that have been proven effective in the treatment of adolescent depression. Medications should be considered for more severe depression or depression failing to respond to psychotherapy.
A Cochrane review found that fluoxetine was the only agent with consistent evidence of effectiveness in decreasing depressive symptoms in adolescents. Consensus guidelines recommend fluoxetine, citalopram, or sertraline as first-line treatments for moderate to severe depression in children and adolescents. Escitalopram is also licensed for the treatment of depression in adolescents age 12 or older.
All antidepressants have a boxed warning regarding an increased risk of suicide; therefore, close monitoring is recommended to assess for suicidality and other adverse effects, such as GI effects, nervousness, HA, and restlessness.
TCAs were previously used to treat depression in children, but studies have shown little to no benefit in adolescents and children.
Which one of the following, when confirmed with a repeat test, meets the diagnostic criteria for diabetes mellitus? (check one)
A. A fasting blood glucose level of 120 mg/dL
B. A 2-hour value of 180 mg/dL on an oral glucose tolerance test
C. A random glucose level of 180 mg/dL in a patient with symptoms of diabetes mellitus
D. A positive urine dipstick for glucose
E. A hemoglobin A1c of 7.0%
E
hemoglobin A1c level ≥6.5% is diagnostic of diabetes mellitus.
Other criteria include:
- fasting plasma glucose level ≥126 mg/dL
- random glucose leve l≥200 mg/dL in a patient with symptoms of diabetes
- 2-hour glucose tolerance test value ≥200 mg/dL
While a urine dipstick may be used to screen for diabetes, it is not a diagnostic test.
You see a 9-year-old female for evaluation of her asthma. She and her mother report that she has shortness of breath and wheezing 3–4 times per week, which improves with use of her albuterol inhaler. She does not awaken at night due to symptoms, and as long as she has her albuterol inhaler with her she does not feel her activities are limited by her symptoms. About once per year she requires prednisone for an exacerbation, often triggered by a viral infection.
Based on this information you classify her asthma severity as: (check one)
A. intermittent
B. mild persistent
C. moderate persistent
D. severe persistent
B
This patient has mild persistent asthma, based on her symptoms occurring more than 2 days per week, but not daily, and use of her albuterol inhaler more than 2 days per week, but not daily.
A 42-year-old white female presents to your office as a new patient. She states that she has an 8-year history of abdominal cramps and diarrhea. Her symptoms have not responded to the usual treatments for irritable bowel syndrome. She has no rectal bleeding, anemia, weight loss, or fever, and no family history of colon cancer. Her medical history and a review of symptoms is otherwise negative, and a physical examination is normal.
Which one of the following would be the most appropriate next step in evaluating this patient?
A. A CBC
B. A TSH level
C. A complete metabolic panel
D. Serologic testing for celiac sprue
E. Stool testing for ova and parasites
D
In patients who have symptoms of diarrhea-predominant IBS, the differential includes celiac sprue, microscopic and collagenous colitis, atypical Crohn’s disease.
For those with constipation-predominant IBS, the differential is chronic constipation
. If there are no warning signs, laboratory testing is warranted only if indicated by the history
A 36-year-old female makes an appointment because her husband of 12 years was just diagnosed with hepatitis C when he tried to become a blood donor for the first time. He recalls multiple blood transfusions following a motorcycle crash in 1988. His wife denies past liver disease, blood transfusions, and intravenous drug use. She has had no other sexual partners. The couple has three children. Which one of the following is the best advice about testing the wife and their three children? (check one)
A. No testing is required in the absence of jaundice or gastrointestinal symptoms
B. No testing is required if her husband has normal liver enzyme levels
C. No testing is required because tests have low sensitivity
D. She should be offered testing because sexual transmission is possible
E. All family members should be tested because of possible household fecal-oral spread
D
Key risk factors for hepatitis C infection are long-term hemodialysis, intravenous drug use, blood transfusion or organ transplantation prior to 1992, and receipt of clotting factors before 1987, and sexual transmission.
The mother should be offered testing and if she is seronegative, the children are at no risk. Maternal-fetal transmission is rare except in the setting of co-infection with HIV. Hepatitis C is insidious, and symptoms do not correlate with the extent of the disease. Normal liver enzyme levels do not indicate lack of infectivity. There is no risk to household contacts.,
The only antidepressant approved by the Food and Drug Administration for the treatment of depression in children 8-17 years of age is (check one)
A. venlafaxine (Effexor)
B. amitriptyline
C. lithium
D. paroxetine (Paxil)
E. fluoxetine (Prozac)
E
A previously healthy 73-year-old male is admitted to the intensive-care unit after an emergency appendectomy. He does well until the evening, when he suddenly appears confused. His speech is rambling and incoherent, and he is disoriented to person, place, and time. His wife says he was sleepy but otherwise acting normal 2 hours ago. On examination he has normal vital signs and no fever. Other than the cognitive changes and some mild peri-incisional tenderness the examination is normal. Serum electrolytes, a CBC, arterial blood gases, and a routine chemistry panel are normal.
The most likely cause for his altered sensorium is
A. sepsis
B. acute psychosis
C. dementia with Lewy bodies
D. delirium
E. ischemic stroke
D
Delirium is common in the postoperative setting.
A 30-year-old male presents with a 3-week history of severe, burning pain in his right shoulder. He recalls no mechanism of injury. An examination reveals weakness to resistance of the biceps and triceps, and with external rotation of the shoulder. Full range of motion of the neck and shoulder does not worsen the pain.
Which one of the following would be most likely to identify the cause of this patient’s problem? (check one)
A. Electromyography and nerve conduction studies
B. MRI of the neck
C. MR arthrography (MRA) of the shoulder
D. CT of the brain
E. Ultrasonography of the upper extremity
A
This patient has brachial neuritis, which can be difficult to differentiate from cervical radiculopathy, shoulder pathology, and cerebrovascular accident. The pain preceded the weakness, no trauma was involved, and the weakness is in a nondermatomal distribution, making brachial neuritis the most likely diagnosis. Electromyography is most likely to show this lesion, but only after 3 weeks of symptoms.
MRI of the neck may show abnormalities, but not the cause of the current problem. Symptoms are not consistent with shoulder pathology, deep-vein thrombosis of the upper extremity, or cerebrovascular accident.
Which one of the following is true concerning postpartum depression? (check one)
A. It has no effect on cognitive development of the child
B. It is directly related to the desired gender of the infant
C. It is usually transient, lasting about 10 days
D. Thyroid function should always be assessed in women with postpartum depression
D
Thyroid function must be evaluated in women with postpartum depression since both hyperthyroidism and hypothyroidism are more common postpartum.
Postpartum depression may impair cognitive and behavioral development in the child. It is not related to the desired gender of the child, breastfeeding, or education level of the mother. It should be differentiated from the short-term “baby blues” that resolve within about 10 days. Sertraline is considered first-line treatment for postpartum depression in women who are breastfeeding.
A 55-year-old male who has a long history of marginally-controlled hypertension presents with gradually increasing shortness of breath and reduced exercise tolerance. His physical examination is normal except for a blood pressure of 140/90 mm Hg, bilateral basilar rales, and trace pitting edema. Which one of the following ancillary studies would be the preferred diagnostic tool for evaluating this patient? (check one)
A. 12-lead electrocardiography
B. Posteroanterior and lateral chest radiographs
C. 2-dimensional echocardiography with Doppler
D. Radionuclide ventriculography
E. Cardiac MRI
C
The most useful diagnostic tool for evaluating patients with heart failure is two-dimensional echocardiography with Doppler to assess left ventricular ejection fraction (LVEF), left ventricular size, ventricular compliance, wall thickness, and valve function. The test should be performed during the initial evaluation. Radionuclide ventriculography can be used to assess LVEF and volumes, and MRI or CT also may provide information in selected patients. Chest radiography (posteroanterior and lateral) and 12-lead electrocardiography should be performed in all patients presenting with heart failure, but should not be used as the primary basis for determining which abnormalities are responsible for the heart failure.
A 24-year-old female presents for her annual examination. She is single and has had several male sexual partners during the past year. You include screening for chlamydial infection in your evaluation, and the test is reported as positive. She is asymptomatic. Which one of the following is true concerning this situation?
A. Failure to treat this patient would place her at higher risk of later infertility
B. Only sexual partners with whom she has been active during the last 2 weeks need to be treated
C. She should avoid sexual intercourse for 1 month after treatment
D. Use of barrier methods of contraception increases her risk for repeat infection
A
It is recommended that sexually active women under the age of 25 years be screened routinely for Chlamydia trachomatis. Treatment of asymptomatic infections in women reduces their risk of developing pelvic inflammatory disease, tubal infertility, ectopic pregnancy, and chronic pelvic pain. A 1-gram dose of oral azithromycin is an appropriate treatment, including during pregnancy. Sexual contacts during the preceding 60 days should be either treated empirically or tested for infection and treated if positive. The patient should avoid sexual intercourse for 7 days after initiation of treatment. Consistent use of barrier methods for contraception reduces the risk of C. trachomatis genital infection.
The mother of a 3-year-old male is concerned that he doesn’t like being held, doesn’t interact much with other children, and rarely smiles. Of the following, which feature would be most helpful in distinguishing Asperger’s syndrome from autism in this patient? (check one)
A. Normal language development
B. Delayed gross motor development
C. Repetitive fine motor mannerisms
D. Preoccupation with parts of objects
E. Focused patterns of intense interest
A
The DSM-IV categorizes Asperger’s syndrome and autism as pervasive developmental disorders. In both conditions, children have significant difficulties with social interactions, although the impairment is more severe and sustained in autism. Both Asperger’s and autism may be associated with symptoms of repetitive motor mannerisms, restricted patterns of interest (which are abnormal in focus or intensity), or preoccupation with parts of objects.
However, unlike children with Asperger’s syndrome, autistic children have serious problems with communication skills, either in the development of speech itself or in the ability to carry on a conversation. It is an important distinction to make, as the prognosis for independent functioning in children with Asperger’s syndrome is significantly better than in children with autism. Ref
An 81-year-old male with type 2 diabetes mellitus has a hemoglobin A 1c of 10.9%. He is already on the maximum dosage of glipizide (Glucotrol). His other medical problems include mild renal insufficiency and moderate ischemic cardiomyopathy.
Which one of the following would be the most appropriate change in this patient’s diabetes regimen? (check one)
A. Add metformin (Glucophage)
B. Add sitagliptin (Januvia)
C. Add pioglitazone (Actos)
D. Initiate insulin therapy
D
This geriatric diabetic patient should be treated with insulin.
Metformin is contraindicated in patients with renal insufficiency.
Sitagliptin should not be added to a sulfonylurea drug initially, the dosage should be lowered in patients with renal insufficiency, and given alone it would probably not result in reasonable diabetic control.
Pioglitazone can cause fluid retention and therefore would not be a good choice for a patient with cardiomyopathy.
You see a 30-year-old white male for the first time for a routine evaluation. He says that he has been bothered by multiple skin lesions on the neck and axillae. On examination you note numerous skin tags.
The presence of these lesions indicates an increased risk for:
(check one)
A. diabetes mellitus
B. squamous cell skin cancer
C. melanoma
D. glioblastoma multiforme
E. AIDS
A
Skin tags, or acrochordons, are associated with DM and obesity. The onset often occurs in early adulthood, and the most common locations are the neck and axillae. These skin lesions are not associated with any significant cancer risk, and have not been associated with HIV infection.
An 80-year-old female is admitted to your service at a skilled nursing facility 5 days after repair of a hip fracture. When you review her records you note that she has not received any previous treatment for osteoporosis. You are considering ordering zoledronic acid (Reclast) to reduce her risk of another fracture. Which one of the following should be evaluated before administering zoledronic acid to this patient?
A. Vitamin D levels B
B. Liver enzyme levels
C. Estimated glomerular filtration rate
D. A CBC
C
Bisphosphonates, including zoledronic acid, can reduce rates of clinical fractures among patients who have had a hip fracture.
- Long-term use may increase the risk of jaw osteonecrosis and
- anemia. Contraindications include hypocalcemia and a creatinine clearance or other evidence of acute renal impairment.
You see a 23-year-old gravida 1 para 0 for her prenatal checkup at 38 weeks gestation. She complains of severe headaches and epigastric pain. She has had an uneventful pregnancy to date and had a normal prenatal examination 2 weeks ago. Her blood pressure is 140/100 mm Hg. A urinalysis shows 2+ protein; she has gained 5 lb in the last week, and has 2+ pitting edema of her legs. The most appropriate management at this point would be: (check one)
A. Strict bed rest at home and reexamination within 48 hours
B. Admitting the patient to the hospital for bed rest and frequent monitoring of blood pressure, weight, and proteinuria
C. Admitting the patient to the hospital for bed rest and monitoring, and beginning hydralazine (Apresoline) to maintain blood pressure below 140/90 mm Hg
D. Admitting the patient to the hospital, treating with parenteral magnesium sulfate, and planning prompt delivery either vaginally or by cesarean section
D
This patient manifests a rapid onset of preeclampsia at term. The symptoms of epigastric pain and headache categorize her preeclampsia as severe. These symptoms indicate that the process is well advanced and that convulsions are imminent. Treatment should focus on rapid control of symptoms and delivery of the infant.
A 70-year-old female had a lumbar vertebral fracture 3 years ago. At that time she had a dual-energy x-ray absorptiometry (DEXA) scan, with a T score of –2.6, and was placed on alendronate (Fosamax), calcium, and vitamin D. She recently quit smoking. Her BMI is 21. A DEXA scan today shows her bone mineral density to be –2.1. Which one of the following would be most appropriate in the management of this patient?
A. Replace alendronate with raloxifene (Evista)
B. Stop alendronate, but continue calcium and vitamin D
C. Add raloxifene to her regimen
D. Add teriparatide (Forteo) to her regimen
E. Make no change to her regimen
E
Even though the patient’s DEXA has improved and she is technically osteopenic, she still has risk factors for osteoporosis, including recent smoking, low BMI, and a prior fragility fracture. She should continue her current regimen.
A 21-year-old African-American female has been confused and delirious for 2 days. She has no significant past medical history, and she is taking no medications. She recently returned from a missionary trip to Southeast Asia. During your initial examination in the ED, she has several convulsions and rapidly becomes comatose. Her temperature is 37.9°C (100.3°F) and her BP 80/50 mm Hg. A neurologic examination shows no signs of meningeal irritation and a cranial nerve evaluation is normal. There is a mild, bilateral, symmetric increase in deep tendon reflexes. All other physical examination findings are normal. Laboratory Findings:
Hemoglobin……………………… 7.0 g/dL (N 12.0–16.0)
Hematocrit………………………. 20% (N 36–46)
WBCs………………………. 6500/mm3 (N 4300–10,800)
Platelets. ……………………….. 450,000/mm3 (N 150,000–350,000)
Serum bilirubin
Total…………………………. 5.0 mg/dL (N 0.3–1.1)
Direct………………………… 1.0 mg/dL (N 0.1–0.4)
The urine is dark red and positive for hemoglobin. CT of the brain shows neither bleeding nor infarction. The most likely diagnosis is: (check one)
A. vitamin B12 deficiency
B. malaria
C. ehrlichiosis
D. sickle cell anemia
B
Clinical clues to the diagnosis of malaria in this case include an appropriately targeted recent travel history, a prodrome of delirium or erratic behavior, unarousable coma following a generalized convulsion, fever, and a lack of focal neurologic signs in the presence of a diffuse, symmetric encephalopathy. The peripheral blood smear shows normochromic, normocytic anemia with Plasmodium falciparum trophozoites and schizonts involving erythrocytes, diagnostic of cerebral malaria. Treatment of this true medical emergency is IV quinidine gluconate.
Vitamin B 12 deficiency is a predominantly peripheral neuropathy seen in older adults. Ehrlichiosis causes thrombocytopenia but not hemolytic anemia. Sickle cell disease presents with painful vaso-occlusive crises in multiple organs. Coma is rare.
A 16-year-old male is brought to your office by his mother for “stomachaches.” On the review of systems he also complains of headaches, occasional bedwetting, and trouble sleeping. His examination is within normal limits. His mother says that he is often in the nurse’s office at school, and doesn’t seem to have any friends. When you discuss these problems with him, he admits to being teased and called names at school. Which one of the following would be most appropriate? (check one)
A. Explain that he must try to conform to be more popular
B. Explain that these symptoms are a stress reaction and will lessen with time
C. Explore whether his school counselor has a process to address this problem
D. Order a TSH level
C
Childhood bullying has potentially serious implications for bullies and their targets. The target children are typically quiet and sensitive, and may be perceived to be weak and different. The presenting symptoms are not temporary, and in fact can progress to more serious problems such as suicide, substance abuse, and victim-to-bully transformation.
Children who say they are being bullied must be believed and reassured that they have done the right thing in acknowledging the problem. Parents should be advised to discuss the situation with school personnel.
A 42-year-old white male develops respiratory distress 12 hours after he sustained a closed head injury and a femur fracture. A physical examination reveals a respiratory rate of 40/min. He has a pO2 of 45 mm Hg (N 75–100), a pCO2 of 25 mm Hg (N 35–45), and a blood pH of 7.46 (N 2 2 7.35–7.45). His hematocrit is 30.0% (N 37.0–49.0).
Of the following, the most likely diagnosis is: (check one)
A. respiratory depression due to central nervous system damage
B. heart failure
C. adult respiratory distress syndrome (ARDS)
D. hypovolemic shock
E. tension pneumothorax
C
1%–2% of significantly injured patients develop acute respiratory failure in the post-injury period. Theory that the lung has a limited number of ways of reacting to injury and that several different types of acute, diffuse lung injury result in a similar pathophysiologic response. The common denominator of this response appears to be injury at the alveolar-capillary interface, with resulting leakage of proteinaceous fluid from the intravascular space into the interstitium and subsequently into alveolar spaces. It has become acceptable to describe this entire spectrum of acute diffuse injury as ARDs
The syndrome of ARDS can occur under a variety of circumstances and produces a spectrum of clinical severity from mild dysfunction to progressive, eventually fatal, pulmonary failure. Fortunately, with proper management, pulmonary failure is far less frequent than milder abnormalities.
As the medical review officer for a local business, you are required to interpret urine drug tests. Assuming the sample was properly collected and handled, which one of the following test results is consistent with the history provided and should be reported as a negative test? (check one)
A. Diazepam (Valium) identified in an employee taking oxazepam prescribed by a physician
B. Morphine identified in an employee undergoing a prescribed methadone pain management program
C. Morphine identified in an employee taking a prescribed cough medicine containing codeine
D. THC above the threshold value in an employee who reports secondary exposure to marijuana
E. THC identified in an employee taking prescribed tramadol (Ultram)
C
When a properly collected, acceptable specimen is found to contain drugs or metabolites that would be expected based on a review of confirmed prescribed use of medications, the test is reported as negative. Morphine is a metabolite of codeine that may be found in the urine of someone taking a codeine-containing medication; morphine is not a metabolite of methadone. Oxazepam is a metabolite of diazepam but the reverse is not true. Tetrahydrocannabinol would not be found in the urine as a result of tramadol use.
A 9-month-old male is seen for a routine well-baby examination. There have been no health problems and developmental milestones are normal. Review of the growth chart shows that length, weight, and head circumference have continued to remain at the 75th percentile. The examination is normal with the exception of the anterior fontanelle being closed. Proper management at this time would include: (check one)
A. A CT scan of the head
B. MRI of the head
C. A CBC, a metabolic profile, and thyroid studies
D. Referral to a neurologist
E. Serial measurement of head circumference
E
The anterior fontanelle closes at 3 months in 1% of cases, and by 1 year, 38% are closed. While early closure of the anterior fontanelle may be normal, the head circumference must be carefully monitored for craniosynostosis (premature closure of one or more sutures) and for abnormal brain development. When craniosynostosis is suspected, a skull radiograph is useful for initial evaluation, and if present, a CT scan should be obtained.
The etiologic agent that causes erysipelas is? (check one)
A. Staphylococcus aureus
B. Haemophilus influenzae
C. Streptococcus pyogenes
D. Pseudomonas aeruginosa
E. Rubivirus
C
Penicillin is an effective treatment.
A slender 22-year-old female is concerned about a recent weight loss of 10 lb, frequent mild abdominal pain, and significant diarrhea of 2 months’ duration. Her physical examination is unremarkable, and laboratory studies reveal only a moderate microcytic, hypochromic anemia. Based on this presentation, which one of the following is the most likely diagnosis? (check one)
A. Irritable bowel syndrome
B. Villous adenoma
C. Infectious colitis
D. Celiac disease
E. Ulcerative colitis
D
his constellation of symptoms strongly suggests celiac disease, which typically present with anemia or osteoporosis, without gastrointestinal symptoms. Individuals with more significant mucosal involvement present with watery diarrhea, weight loss, and vitamin and mineral deficiencies.
A 72-year-old female with longstanding diabetes mellitus presents to your office. During the review of systems, she complains of difficulty voiding and frequent “dribbling.” A urinalysis is negative for infection and her post-void residual volume is 250 mL. Which one of the following is the most likely cause of this patient’s urinary incontinence? (check one)
A. Excess urine output due to hyperglycemia
B. Atrophic vaginitis
C. A grade II cystocele
D. Asymptomatic bacteriuria
E. Autonomic neuropathy
E
Dribbling + increased post-void residual volume (>100 mL) are signs of overflow incontinence - can be caused by outflow obstruction (e.g., prostate hypertrophy, urethral constriction, fecal impaction) or, as in this case, by detrusor muscle denervation caused by diabetic or other neuropathies.
Excess urine output from hyperglycemia would result in frequent urination, but not urinary retention. Atrophic vaginitis and cystoceles are usually associated with stress incontinence. Asymptomatic bacteriuria is unlikely because the patient does not have any evidence of infection.
A 27-year-old male requests your advice regarding colon cancer screening. His brother died of colon cancer, which was diagnosed at the age of 40. You suggest that he begin colonoscopy screening? (check one)
A. Now
B. At age 30
C. At age 40
D. At age 45
E. At age 50
B
Average-risk adults should be screened for colon cancer starting at 50 years of age, and high-risk adults either at age 40 or 10 years before the age at which colorectal cancer was diagnosed in the youngest affected relative.
A 17-year-old white female has a history of anorexia nervosa, and weight loss has recently been a problem. The patient is an academically successful high-school student who lives with her parents and a younger sibling. Her BMI is 17.4 kg/m2 . Her serum electrolyte levels and an EKG are normal.
Which one of the following interventions is most likely to be successful? (check one)
A. Family-based treatment
B. Adolescent-focused individual therapy
C. Fluoxetine (Prozac)
D. Phenelzine (Nardil)
E. Desipramine (Norpramin)
A
Family-based treatment for the adolescent with anorexia nervosa has been found to provide superior results when compared with individual adolescent-focused therapy (SOR B). Antidepressants have not been successful. They may be indicated for coexisting conditions, but this is more common with bulimia.
A 65-year-old male who has been in good health presents to your office with a 2-day history of a sensation of pressure and hearing loss in his left ear. A physical examination and a thorough neurologic examination are both unremarkable. Both tympanic membranes are normal. An audiogram shows a 30-decibel hearing loss at three consecutive frequencies in the left ear, with normal hearing on the right. Placing a vibrating tuning fork in the midline of the forehead reveals sound lateralizing to the right ear. Which one of the following would be most appropriate at this point? (check one)
A. CT
B. A CBC, metabolic profile, and thyroid studies
C. Nifedipine (Procardia)
D. Acyclovir (Zovirax)
E. Oral corticosteroids
E
When a patient presents with sudden hearing loss it is important to distinguish between sensorineural vs. conductive hearing loss. Patients should be asked about previous episodes, and the workup should include both an assessment for bilateral hearing loss and a neurologic examination. Sudden sensorineural hearing loss is diagnosed by audiometry demonstrating a 30-decibel hearing loss at three consecutive frequencies, with no other cause indicated from the physical examination. Evaluation for retrocochlear pathology may include auditory brainstem response, MRI, or follow-up audiometry.
Oral corticosteroids may be offered as initial therapy, and hyperbaric oxygen therapy may be helpful within 3 months of diagnosis. Routinely prescribing antiviral agents, thrombolytics, vasodilators, vasoactive substances, or antioxidants is not recommended. The guidelines also strongly recommend against routine laboratory tests or CT of the head as part of the initial evaluation.
A 67-year-old female is admitted to the hospital with severe community-acquired pneumonia. Her urine should be tested for which one of the following antigens? (check one)
A. Chlamydia
B. Mycoplasma
C. Legionella
D. Haemophilus influenzae
E. Pseudomonas
C
In patients with severe pneumonia, the urine should be tested for antigens to Legionella and pneumococcus. Two blood cultures should also be drawn, but these are positive in only 10%–20% of all patients with CAP
You have just received test results confirming that a 78-year-old patient has metastatic lung cancer. She informs you she does not want to know the results of the tests and is “leaving it in God’s hands.” You know that additional issues need to be explored, such as her desire for chemotherapy and hospice care.
Which one of the following is the most appropriate strategy for determining her wishes?
A. Acknowledge her concerns, but proceed with a discussion of her diagnosis and prognosis
B. Ask family members to gently break the news to your patient and tell them you will return later to discuss the details and answer questions
C. Have a hospice representative visit and discuss the diagnosis and options for care
D. Ask the patient to designate someone with whom you can discuss the results and prognosis
D
In a patient-centered approach to communication regarding end-of-life care, a patient’s wishes to not know about a diagnosis or prognosis should be respected. However, it is reasonable to ask the patient to name a proxy with whom you may discuss the issues. The other options listed do not respect the patient’s desire to not know her diagnosis or prognosis.
You have recently begun caring for a 25-year-old white female who has multiple complaints. You have seen her 3 times for walk-in office visits over the past month. She has shown appreciation for your work during the encounters, but has been critical of your care when talking to the office staff. At times she has been kind and charming, and at other times she has been rude and verbally abusive to your staff. She has a string of multiple relationships in the past, none of which has lasted very long. During times of intense stress, she has sometimes engaged in self-mutilation. She frequently changes jobs and living arrangements. Which one of the following strategies would be most appropriate in the care of this patient? (check one)
A. Strive to develop a close relationship with the patient
B. Ignore verbal attacks on staff members
C. Prescribe lorazepam (Ativan)
D. Schedule frequent office visits for follow-up
E. Provide detailed, technical explanations for any therapies provided
D
Patients with borderline personality disorder often demonstrate instability in interpersonal relationships and self-image, and may be impulsive. They can present with a wide range of symptoms, including depression, anger, paranoia, extreme dependency, self-mutilation, and alternating idealization and devaluation of their physicians. Their lives are often chaotic.
Treatment strategies include maintaining a caring but somewhat detached professional stance. A close personal relationship is typically not therapeutic for these patients. Angry outbursts will often have to be tolerated, but limit-setting is necessary with respect to appropriate behaviors. SSRIs, atypical antipsychotics, and mood stabilizers may be of help at times, but anxiolytics are often abused and may be associated with self-mutilating behaviors. These patients tend to respond best to clear, simple, non-technical explanations related to their medical care.
Your patient is moving to another state and requests transfer of his medical records. Which one of the following is true regarding this patient’s request? (check one)
A. The medical record should be released only with written permission from a patient or legal representative
B. Although it is kept by the physician, the physical paper or electronic medical record is the property of the patient
C. A physician may withhold medical record information that could cause undue stress to a patient
D. In spite of a patient request, the physician may withhold information from a third party
E. A physician has the right to withhold the medical record until medical bills are paid in full
A
Permission for the release of patient information should always be in writing. Although the actual medical record is the property of the physician, the information in the chart is the property of the patient. Ethically and legally, patients have a right to the information in their medical records, and it cannot be withheld from the patient or a third party (at the request of the patient), even if medical bills are unpaid or the physician is concerned about the patient.
A 63-year-old male with type 2 diabetes mellitus is seen in the emergency department for an acute, superficial, previously untreated infected great toe. Along with Staphylococcus aureus, which one of the following is the most common pathogen in this situation? (check one)
A. Pseudomonas
B. Streptococcus
C. Clostridium
D. Escherichia coli
E. Adenovirus
B
The most common pathogens in previously untreated acute superficial foot infections in diabetic patients are aerobic gram-positive Staphylococcus aureus and β-hemolytic streptococci (groups A, B, others).
Previously treated and deep infections are often polymicrobial
A 34-year-old female with a history of bilateral tubal ligation consults you because of excessive body and facial hair. She has a normal body weight, no other signs of virilization, and regular menses.
Which one of the following is the most appropriate treatment for her mild hirsutism? (check one)
A. Spironolactone (Aldactone)
B. Leuprolide (Lupron)
C. Prednisone
D. Metformin (Glucophage)
A
Antiandrogens such as spironolactone, along with oral contraceptives, are recommended for treatment of hirsutism in premenopausal women
A 55-year-old male presents for an evaluation of heel pain. He has a relatively sedentary office job, but exercises daily by jogging 3 miles. He has pain in the right heel at the medial aspect of the calcaneus and is tender on examination. The pain is worse with the first few steps of the morning. Which one of the following would be the most appropriate initial treatment for this patient? (check one)
A. Corticosteroid injection
B. Extracorporeal shockwave therapy
C. Surgical referral for bone spur removal
D. Non-weight bearing for 1 month
E. Stretching exercises for the Achilles tendon
E
Plantar fasciitis - overuse injury due to microtrauma of the plantar fascia where it attaches at the medial calcaneal tubercle -> heel or arch pain, which often is worse upon arising and pain with first few steps of the morning. Examination reveals tenderness at the site and pain with dorsiflexion of the toes. treatment includes rest, ice, NSAIDs, and shoe inserts with arch support, heel cord and plantar fascia stretching. Currently, there is evidence against the use of extracorporeal shockwave therapy. If conservative therapy fails, a corticosteroid injection may be useful. Surgery is reserved for patients refractory to 6-12 months of uninterrupted conservative therapy.
Stress fractures - pain at rest that intensifies with weight bearing; treatment includes rest, ice, NSAIDs, and shoe inserts with arch support, heel cord and plantar fascia stretching.
45-year-old white male presents with severe intermittent right flank pain that radiates into his right groin area. You suspect a ureteral stone. Which one of the following would most reliably confirm your suspected diagnosis? (check one)
A. A helical CT scan of the abdomen and pelvis without contrast
B. Intravenous pyelography
C. Abdominal ultrasonography
D. A KUB plain film of the abdomen
E. A urinalysis
A
An unenhanced helical CT scan of the abdomen and pelvis is the best study for confirming the diagnosis of a urinary tract stone in a patient with acute flank pain. A CT scan may also reveal other pathology, such as appendicitis, diverticulitis, or abdominal aortic aneurysm. Although abdominal ultrasonography has a very high specificity, it is still not better than CT, and its sensitivity is much lower; thus, its use is usually confined to pregnant patients with a suspected stone. Plain abdominal radiographs may show the stone if it is radiopaque, and are useful for following patients with radiopaque stones. CT will reveal a radiopaque stone. While most patients with stones will have hematuria, its absence does not rule out a stone.
The U.S. Preventive Services Task Force (USPSTF) has stated that the potential cardiovascular benefits of daily aspirin use outweigh the potential harms of gastrointestinal hemorrhage in certain populations. The USPSTF currently recommends daily aspirin use for which one of the following populations? (check one)
A. Males 25–44 years of age
B. Males over 80 years of age
C. Females 25–44 years of age
D. Females over 45 years of age
E. Females 55–79 years of age
E
USPSTF) recommends daily aspirin use for
- males 45–79 years of age when the potential benefit of a reduction in myocardial infarction outweighs the potential harm of an increase in gastrointestinal hemorrhage
- females 55–79 years of age when the potential benefit of a reduction in ischemic strokes outweighs the potential harm of an increase in gastrointestinal hemorrhage
The USPSTF has concluded that the current evidence is insufficient to assess the balance of benefits and harms of aspirin for cardiovascular disease prevention in men and women 80 years of age or older. It recommends against the use of aspirin for stroke prevention in women younger than 55, and for myocardial infarction prevention in men younger than 45
A newborn male has a skin eruption on his forehead, nose, and cheeks. The lesions are mostly closed comedones with a few open comedones, papules, and pustules. No significant erythema is seen. Which one of the following is the most likely diagnosis? (check one)
A. Erythema toxicum neonatorum
B. Localized superficial Candida infection
C. Herpes simplex
D. Milia
E. Acne neonatorum
E
Acne neonatorum occurs in up to 20% of newborns. It typically consists of closed comedones on the forehead, nose, and cheeks, and is thought to result from stimulation of sebaceous glands by maternal and infant androgens. Parents should be counseled that lesions usually resolve spontaneously within 4 months without scarring.
Findings in erythema toxicum neonatorum include papules, pustules, and erythema.
Candida and herpes lesions usually present with vesiculopustular lesions in the neonatal period.
Milia consists of 1- to 2-mm pearly keratin plugs without erythema, and may occur on the trunk and limbs.
Patients treated with which one of the following require regular hematologic monitoring for the development of granulocytopenia? (check one)
A. Olanzapine (Zyprexa)
B. Haloperidol (Haldol)
C. Clozapine (Clozaril)
D. Fluphenazine (Prolixin)
E. Risperidone (Risperda
C
Clozapine is a second-generation antipsychotic, which are believed to be less likely to cause extrapyramidal side effects than the first-generation drugs such as haloperidol or the phenothiazines (e.g., fluphenazine). It is generally considered second-line therapy, to be used in cases unresponsive to other drugs.
A 2003 meta-analysis concluded that clozapine was the most efficacious second-generation antipsychotic, followed by risperidone and olanzapine. However, clozapine use is associated with an approximately 1% incidence of granulocytopenia / agranulocytosis. Early detection by monitoring CBCs every 1–2 weeks has led to a reduction in agranulocytosis-related death.
A 32-year-old female has a 3-week history of depressed mood. She reports markedly diminished interest or pleasure in most activities, fatigue, a diminished ability to concentrate, and insomnia. She has had recurrent suicidal thoughts, but has no specific plan. Further investigation reveals a past history of several hypomanic episodes lasting 4–5 days, characterized by a persistently elevated, expansive mood. During these episodes she needed little sleep, was talkative, met multiple goals, and had trouble keeping up with the thoughts that were running through her head. She was treated with lithium in her early twenties but she stopped taking it because it stifled her artistic creativity. She currently takes no medication.
Her physical examination is unremarkable. Results from comprehensive laboratory studies, including a urine toxicology screen, are also normal.
Which one of the following is most appropriate for her current depressive symptoms?
A. Aripiprazole (Abilify)
B. Venlafaxine
C. Divalproex (Depakote)
D. Divalproex and bupropion (Wellbutrin)
E. Lithium and paroxetine (Paxil)
C
This patient has bipolar II disorder. She has a history of hypomanic episodes as well as major depression, with no history of a manic or mixed episode. Among the pharmacologic options listed, only divalproex and lithium are indicated for treating bipolar depression or acute mania, and for maintenance. They should be given as single agents, however, not in combination with other drugs, as studies have shown that initially adding paroxetine or bupropion to the mood stabilizer was no more effective than using lithium or valproate.
55-year-old female is concerned about variations in her heartbeat. She describes “fluttering,” “flip-flopping,” and sometimes “pounding” sensations in her chest, with occasional delays between beats. Her symptoms are episodic, and have been occurring for several months. They have not been present for the past week.
The patient’s family history is negative for thyroid disease, but she recalls some “heart trouble” in several family members that was accompanied by fainting spells, and at least one relative died suddenly. She takes no medications, has a negative psychiatric review of systems, and has a normal physical examination.
Which one of the following would be most appropriate at this point?
(check one)
A. Reassurance that her symptoms are associated with a benign condition
B. A standard 12-lead EKG
C. Echocardiography
D. Intermittent event (loop) cardiac monitoring
B
All patients who present with palpitations should be evaluated for a cardiac cause, since this is the etiology in 43% of cases. A standard 12-lead EKG is the initial test of choice and, along with a history and physical examination, can determine the cause in 40% of cases. A normal resting EKG does not exclude a cardiac arrhythmia. Therefore, if the EKG is normal, palpitations of suspected arrhythmic etiology may require further investigation with ambulatory EKG monitoring.
Echocardiography is helpful in evaluating patients for structural heart disease and should be performed when the initial history, physical examination, and EKG are unrevealing, or in patients with a history of cardiac disease or more complex signs and symptoms. This patient’s family history, along with the fact that she takes no medications, suggests the possibility of familial long QT syndrome, which often can be diagnosed from a resting EKG. Diagnosing long QT syndrome is important, since it is associated with an increased risk of sudden cardiac death. Based on the patient’s clinical presentation and evaluation, hospital admission is not warranted prior to obtaining a standard 12-lead EKG.
Which one of the following medications should be discontinued in a patient with diabetic gastroparesis? (check one)
A. Exenatide (Byetta)
B. Benazepril (Lotensin)
C. Metformin (Glucophage)
D. Hydrochlorothiazide
E. Prochlorperazine maleate
A
Delayed gastric emptying may be caused or exacerbated by medications for diabetes, including amylin analogues (e.g., pramlintide) and glucagon-like peptide 1 (e.g., exenatide). In a clinical trial of exenatide, nausea occurred in 57% of patients and vomiting occurred in 19%, which led to the cessation of treatment in about one-third of patients.
Delayed gastric emptying has a direct effect on glucose metabolism, in addition to being a means of reducing the severity of postprandial hyperglycemia.
The other medications listed do not cause delayed gastric emptying
A 12-year-old male is brought to your office with an animal bite. After talking with the patient, you learn that he was bitten on his left hand as he attempted to pet a stray cat a little over 24 hours ago. He says that the bite was very painful, and that it bled for a few minutes. His parents cared for the bite by rinsing it and covering it with a bandage. His chart indicates that he received a tetanus shot last year.
On examination, the patient is afebrile with stable vital signs. The site is warm and tender to light palpation, with surrounding erythema measuring approximately 3 cm in diameter.
Which one of the following is the most likely infectious agent in this situation? (check one)
A. Candida albicans
B. Capnocytophaga canimorsus
C. Methicillin-resistant Staphylococcus aureus (MRSA)
D. Pasteurella multocida
E. Streptococcus pneumoniae
D
Cat bites that become infected with Pasteurella multocida can be complicated by cellulitis, which may form around the wound within 24 hours. The use of prophylactic antibiotics is associated with a statistically significant reduction in the rate of infection in hand bites. If infection develops and is left untreated, the most common complications are tenosynovitis and abscess formation; however, local complications can include septic arthritis and osteomyelitis. Fever, regional adenopathy, and lymphangitis are also seen.
Which one of the following unimmunized patients should receive two doses of influenza vaccine? (check one)
A. A 5-year-old with asthma
B. A 10-year-old with cystic fibrosis
C. A 15-year-old with sickle cell anemia
D. A 30-year-old with HIV infection
E. A 65-year-old with bullous emphysema
A
2 doses of influenza vaccine are recommended for children unless they have been vaccinated previously. Children 3–8 years of age should receive one or two 0.5-mL doses of split-virus vaccine intramuscularly.
Which one of the following is necessary to make a diagnosis of polymyalgia rheumatica? (check one)
A. Joint swelling
B. Early morning stiffness
C. Reduction of symptoms with high-dose NSAID therapy
D. An erythrocyte sedimentation rate ≥60 mm/hr
E. Bilateral shoulder or hip stiffness and aching
E
There must be bilateral shoulder or hip stiffness and aching for at least one month in order to make the diagnosis of polymyalgia rheumatica.
Joint swelling occurs occasionally, but neither swelling nor early morning stiffness is necessary to make the diagnosis.
Polymyalgia rheumatica does not respond to NSAIDs.
The erythrocyte sedimentation rate should be ≥40 mm/hr.
Which one of the following is the most common cause of hypertension in children under 6 years of age? (check one)
A. Essential hypertension
B. Pheochromocytoma
C. Renal parenchymal disease
D. Hyperthyroidism
E. Excessive caffeine use
C
Although essential hypertension is most common in adolescents and adults, it is rarely found in children less than 10 years old and should be a diagnosis of exclusion. The most common cause of hypertension is renal parenchymal disease, and a urinalysis, urine culture, and renal ultrasonography should be ordered for all children presenting with hypertension. Other secondary causes, such as pheochromocytoma, hyperthyroidism, and excessive caffeine use, are less common, and further testing and/or investigation should be ordered as clinically indicated.
A 30-year-old female presents to your office for an initial visit. She reports a long history of asthma that currently awakens her three times per month, necessitating the use of an albuterol inhaler (Proventil, Ventolin).
According to current guidelines, which one of the following would be optimal treatment?
A. Continued use of a short-acting β-agonist only as needed
B. Adding a long-acting β-agonist
C. Adding a leukotriene receptor antagonist
D. Adding a low-dose inhaled corticosteroid
E. Adding theophyllin
D
Inhaled corticosteroids improve asthma control more effectively in children and adults than any other single long-term controller medication (SOR A). This patient has mild persistent asthma and should be treated with a low-dose inhaled corticosteroid.
A 55-year-old male sees you for a follow-up visit for hypercholesterolemia and hypertension. He is in good health, does not smoke, and drinks alcohol infrequently. His medications include a multiple vitamin daily; aspirin, 81 mg daily; lisinopril (Prinivil, Zestril), 10 mg daily; and lovastatin (Mevacor), 20 mg daily. His vital signs are within normal limits except for a BMI of 33.4 kg/m2 .
At today’s visit his ALT (SGPT) level is 55 IU/L (N 10–45) and his AST (SGOT) level is 44 IU/L (N 10–37). The remainder of the liver panel is normal.
Which one of the following is the most likely cause of the elevation in liver enzymes? (check one)
A. A side effect of lovastatin
B. Gallbladder disease
C. Hepatitis A
D. Alcoholic liver disease
E. Metabolic syndrome
E
Nonalcoholic steatohepatitis (NASH) is the most common cause of abnormal liver tests in the developed world. Its prevalence increases with age, BMI, and triglyceride concentrations, and in patients with DM, HTN, or insulin resistance. There is a significant overlap between metabolic syndrome and diabetes mellitus, and NAFLD is regarded as the liver manifestation of insulin resistance.
Statin therapy is considered safe in such individuals and can improve liver enzyme levels and reduce cardiovascular morbidity in patients with mild to moderately abnormal liver tests that are potentially attributable to NAFLD.
Which cardiac arrhythmia has been reported with high-dose methadone use? (check one)
A. Atrial fibrillation
B. Paroxysmal supraventricular tachycardia
C. Third degree heart block
D. Torsades de pointes
E. Multifocal atrial tachycardia
D
The cardiac toxicity of methadone is related to QT prolongation and torsades de pointes
Which one of the following is a frequent cause of cross-reactive food-allergy symptoms in latex-allergic individuals? (check one)
A. Avocadoes
B. Goat’s milk
C. Pecans
D. Pastrami
E. Peppermint
A
The majority of patients who are latex-allergic are believed to develop IgE antibodies that cross-react with some proteins in plant-derived foods (bananas, avocadoes, and kiwi). These food antigens do not survive the digestive process, and thus lack the capacity to sensitize after oral ingestion in the traditional food-allergy pathway. Antigenic similarity with proteins present in latex, to which an individual has already been sensitized, results in an indirect allergic response limited to the exposure that occurs prior to alteration by digestion, localized primarily in and around the oral cavity. The frequent association with certain fruits has been labeled the “latex-fruit syndrome.”
A 9-month-old white male is brought to your office for a well-child visit. You note that the child’s weight gain has been flat over the last several months. He has fallen from the 75th percentile to the 15th for weight, and his percentile for length is beginning to decline as well. The mother states that the child began having diarrhea as soon as she began giving him various grain cereals and baby foods 5 months ago. The remainder of a review of systems and a social and family history is unremarkable. Physical examination reveals an undernourished infant with mild abdominal distention. A check of the infant’s hemoglobin shows a microcytic anemia with a low serum ferritin level. Which one of the following is the most likely diagnosis?
A. Thalassemia minor
B. Celiac sprue
C. Cystic fibrosis
D. Congenital megacolon (Hirschsprung’s disease)
E. Inborn error of metabolism
B
Celiac sprue is a condition of acquired malabsorption where children develop inflammation and destruction of the microvilli in the small intestine as a result of an immune response to gluten. Patients with celiac sprue often present as this child has, between 4 and 24 months of age with impaired growth, diarrhea, and abdominal distention.
An iron deficiency anemia can occur with impairment of iron absorption from the small intestine. Lesser cases of malabsorption are common, and this condition often goes unrecognized into adolescence or adulthood. Serologic tests, and ultimately a biopsy of the small intestine, can confirm the diagnosis
A 65-year-old white female comes to your office with evidence of a fecal impaction which you successfully treat. She relates a history of chronic laxative use for most of her adult years. After proper preparation, you perform sigmoidoscopy and note that the anal and rectal mucosa contain scattered areas of bluish-black discoloration. Which one of the following is the most likely explanation for the sigmoidoscopic findings? (check one)
A. Endometriosis
B. Collagenous colitis
C. Melanosis coli
D. Metastatic malignant melanoma
E. Arteriovenous malformations
C
melanosis coli - black or brown discoloration of the mucosa of the colon; results from the presence of dark pigment in large mononuclear cells or macrophages in the lamina propria of the mucosa; most intense just inside the anal sphincter and is lighter higher up in the sigmoid colon. The condition is thought to result from fecal stasis and the use of anthracene cathartics such as cascara sagrada, senna, and danthron.
Ectopic endometrial tissue (endometriosis) most commonly involves the serosal layer of those parts of the bowel adjacent to the uterus and fallopian tubes, particularly the rectosigmoid colon. Collagenous colitis does not cause mucosal pigmentary changes. Melanoma rarely metastasizes multicentrically to the bowel wall. Multiple arteriovenous malformations are more common in the proximal bowel, and would not appear as described.
The results of a given study are reported as achieving significance at a p-value of A. There is a 5% likelihood of the results having occurred by chance alone
B. If the study were replicated 100 times, 95 studies would repeat this finding and 5 would not
C. The confidence interval is 0%–10%
D. The null hypothesis has a 5% chance of being true
E. The B or type II error is
A
The p-value is a level of statistical significance, and characterizes the likelihood of achieving the observed results of a study by chance alone, and in this case that likelihood is 5%. (In this case, 5% or less of the results can be achieved by chance alone and still be significant.)
The confidence interval is a measure of variance and is derived from the test data.
The p-value in and of itself says nothing about the truth or falsity of the null hypothesis, only that the likelihood of the observed results occurring by chance is 5%.
The a or type I error is akin to the error of false-positive assignment; the B or type II error is analogous to the false-negative rate, or 1 - specificity, and cannot be calculated from the information given.
You see a 30-year-old male who has just fallen on an outstretched hand. He complains of wrist pain and edema. Examination reveals tenderness over the anatomic snuffbox and over the scaphoid tubercle at the proximal wrist crease with the hand in extension. Radiographs of the wrist are negative. Which one of the following would be the most appropriate action at this point? (check one)
A. Order a bone scan for the next day
B. Order high-spatial-resolution ultrasonography of the wrist
C. Immobilize in a cast for 6–8 weeks
D. Immobilize in a thumb spica splint for 1–2 weeks and then order repeat radiographs
D
Snuffbox tenderness and tenderness over the scaphoid tubercle are very sensitive for fracture of the scaphoid, but their specificity is only 40% and 60% respectively. Therefore, while the lack of tenderness at these sites almost rules out fracture, further imaging is needed in positive cases. A follow-up films after immobilization for 2 weeks should be done if the initial films are negative.
Screening for colon cancer would be recommended for which one of the following patients? (check one)
A. A 35-year-old male whose mother was diagnosed with colon cancer at age 52
B. A 40-year-old female whose mother was diagnosed with colon cancer at age 54
C. A 44-year-old female whose father had a tubular adenoma D. A 46-year-old male whose paternal uncle was diagnosed with colon cancer at age 51
E. A 48-year-old female whose father was diagnosed with colon cancer at age 74
B
A history of a first degree relative diagnosed with colon cancer before age 60 predicts a higher lifetime incidence of colorectal cancer (CRC) and a higher yield on colonoscopic screening. The overall colon cancer risk for these persons is three to four times that of the general population. Screening should consist of colonoscopy, beginning at age 40 or 10 years before the age at diagnosis of the youngest affected relative, whichever comes first.
Earlier screening is no longer recommended for patients who have a single first degree relative with CRC diagnosed at 60 years of age or after, or if there is a family history of adenomas in a first-degree relative
A 48- yo F presents as a new patient to your office. She has not seen a physician for several years and her medical history is unknown. Her BMI is 24.4 kg/m2 and she is not taking any medication. Her blood pressure is 172/110 mm Hg in the left arm sitting and 176/114 mm Hg in the right arm sitting; her cardiovascular examination is otherwise unremarkable. A baseline metabolic panel reveals a creatinine level of 0.68 mg/dL (N 0.6–1.1) and a potassium level of 3.3 mEq/L (N 3.5–5.5).
If the patient’s hypertension should prove refractory to treatment, which one of the following tests is most likely to reveal the cause of her secondary hypertension?
A. A 24-hour urine catecholamine level
B. A plasma aldosterone/renin ratio
C. MRA of the renal arteries
D. Echocardiography
E. A sleep study (polysomnography)
B
Primary hyperaldosteronism is the most common cause of secondary HTN in the middle-aged population, and can be diagnosed with a renin/aldosterone ratio. This diagnosis is further suggested by the finding of hypokalemia –> suggests hyperaldosteronism even though it is not present in the majority of cases.
An echocardiogram would help make a diagnosis of coarctation of the aorta, but this is more common in younger patients.
Renal MRA may demonstrate renal artery stenosis, but this condition is more common in older patients.
Sleep apnea is increasing in prevalence along with the rise in obesity, but it is not suggested by this case.
A 24-hour urine catecholamine test is used to diagnose pheochromocytoma, which is not suggested by this patient’s findings. Pheochromocytoma is also less common than aldosteronism.
Which one of the following is the most reliable clinical symptom of uterine rupture? (check one)
A. Sudden, tearing uterine pain
B. Vaginal bleeding
C. Loss of uterine tone
D. Fetal distress
D
Signs of fetal distress has proven to be the most reliable clinical symptom of uterine rupture. The “classic” signs of uterine rupture such as sudden, tearing uterine pain, vaginal hemorrhage, and loss of uterine tone or cessation of uterine contractions are not reliable and are often absent. Pain and bleeding occur in as few as 10% of cases. Even ruptures monitored with an IUPC fail to show loss of uterine tone.
A previously healthy 22-year-old female presents for her regular prenatal checkup at 38 weeks’ gestation. She has a blood pressure of 145/95 mm Hg today and this is unchanged 1 hour later. Her blood pressure was normal before pregnancy. She is otherwise feeling well. She has moderate edema at the ankles and 3+ reflexes at the knees and ankles. A urinalysis for protein is normal. Given this presentation, which one of the following is the most likely diagnosis? (check one)
A. Preeclampsia
B. Unmasked chronic hypertension
C. Essential hypertension
D. Gestational hypertension
E. Hemolysis, elevated liver enzymes, low platelets (HELLP) syndrome
D
This patient has gestational HTN - diagnosed when elevated BP without proteinuria develops after 20 weeks’ gestation and BP returns to normal within 12 weeks of delivery.
The new criteria for preeclampsia - new onset of HTN (SBP >140 mm Hg or DBP >90 mm Hg) after 20 weeks’ gestation, along with 300 mg protein in a 24-hour urine specimen. A certain amount of increase in blood pressure is no longer a criterion. Edema is also no longer a criterion. Elevated uric acid levels are no longer considered necessary for the diagnosis of preeclampsia. Chronic hypertension can only be diagnosed if present before pregnancy, or if it does not resolve by 12 weeks post partum. Essential hypertension is the most common cause of chronic hypertension. HELLP syndrome is a serious, but relatively rare, form of pregnancy-related hypertension associated with hemolysis, elevated liver enzymes, and low platelets
A 68-year-old female has an average blood pressure of 150/70 mm Hg despite appropriate lifestyle modification efforts. Her only other medical problems are osteoporosis and mild depression. The most appropriate treatment at this time would be (check one)
A. lisinopril (Prinivil, Zestril)
B. clonidine (Catapres)
C. propranolol (Inderal)
D. amlodipine (Norvasc)
E. hydrochlorothiazide
E
Randomized, placebo-controlled trials have shown that isolated systolic hypertension in the elderly responds best to diuretics and to a lesser extent, β-blockers. Diuretics are preferred, although long-acting dihydropyridine calcium channel blockers may also be used. In the case described, β-blockers or clonidine may worsen the depression. Thiazide diuretics may also improve osteoporosis, and would be the most cost-effective and useful agent in this instance.
You are treating an 18-year-old white male college freshman for allergic rhinitis. It is September, and he tells you that he has severe symptoms every autumn that impair his academic performance. He has a strongly positive family history of atopic dermatitis.
Which one of the following medications is considered optimal treatment for this condition? (check one)
A. Intranasal glucocorticoids
B. Intranasal cromolyn sodium
C. Intranasal decongestants
D. Intranasal antihistamines
A
Intranasal glucocorticoids are the most efficacious treatment for allergic rhinitis. They are far superior to oral preparations in terms of safety.
Cromolyn sodium is also an effective topical agent for allergic rhinitis; however, it is more effective if started prior to the season of peak symptoms.
Because of the high risk of rhinitis medicamentosa with chronic use of topical decongestants, these agents have limited usefulness in the treatment of allergic rhinitis.
Azelastine, an intranasal antihistamine, is effective for controlling symptoms but can cause somnolence and a bitter taste.
Oral antihistamines are not as useful for congestion as for sneezing, pruritus, and rhinorrhea
Which one of the following treatments for childhood nocturnal enuresis has both the highest cure rates and the lowest relapse rates? (check one)
A. Bed-wetting alarms
B. Positive reinforcement
C. Responsibility training
D. Desmopressin (DDAVP)
E. Imipramine (Tofranil)
A
Treatments available for childhood nocturnal enuresis include nonpharmacologic and pharmacologic treatments. Compared to other techniques and pharmacologic treatments, the bed-wetting alarm has a higher success rate (75%) and a lower relapse rate (41%).
Treatment with which one of the following antihypertensive medications may mimic the effects of primary hyperparathyroidism? (check one)
A. Amlodipine (Norvasc)
B. Doxazosin (Cardura)
C. Hydrochlorothiazide
D. Lisinopril (Prinivil, Zestril)
E. Metoprolol (Lopressor, Toprol-XL)
C
An elevated parathyroid hormone (or a level that is in an unexpected “normal” range) + elevated calcium generally indicates a diagnosis of primary hyperparathyroidism.
However, these laboratory findings may also occur with lithium or thiazide use, tertiary hyperparathyroidism associated with end-stage renal failure, or familial hypocalciuric hypercalcemia, and a medical and family history should be obtained to assess these possibilities. The other medications listed do not cause hypercalcemia.
A 40-year-old female presents with a complaint of fatigue. She says she is also concerned because she has gained about 10 lb over the last several months. Physical examination reveals no enlargement or other abnormalities of the thyroid gland. Laboratory testing reveals a TSH level of 0.03 μU/mL (N 0.4–4.0) and a free T4 level of 1.0 μg/dL (N 1.5–5.5).
Which one of the following is the most likely cause of her problem? (check one)
A. Malnutrition
B. Graves’ disease
C. Goiter
D. Hashimoto’s thyroiditis
E. Pituitary failure
E
This patient’s symptoms and laboratory findings suggest a significant lack of TSH despite low levels of circulating thyroid hormone. This is diagnostic of secondary hypothyroidism. Such findings should prompt a workup for a pituitary or hypothalamic deficiency that is causing a lack of TSH production.
Primary hypothyroidism, such as Hashimoto’s thyroiditis, would be evidenced by an elevated TSH and low (or normal) T4 .
Graves’ disease is a cause of hyperthyroidism, which would be expected to increase T4 levels, although low TSH with a normal T4 level may be present. The patient does not have the thyroid gland enlargement seen with goiter.
Some nonthyroid conditions such as malnutrition may suppress T4 . In such cases the TSH would be elevated or normal. This patient has gained weight, which does not coincide with malnutrition.
A previously healthy gravida 1 para 1 who is 3 weeks post partum complains of bilateral nipple pain with breastfeeding. When she first started breastfeeding she had some soreness that went away after repositioning with feeding. The current pain began gradually 3 days ago. It has been worsening, inhibiting feeding, and is present between feedings. Examination of the breast is notable for erythema and cracking of the areola.
The most likely cause is: (check one)
A. engorgement
B. mastitis
C. improper latch-on
D. eczema flare
E. Candida infection
E
In breastfeeding women, bilateral nipple pain with and between feedings after initial soreness has resolved is usually due to Candida.
Pain from engorgement typically resolves after feeding.
Mastitis is usually unilateral and is associated with systemic symptoms and wedge-shaped erythema of the breast tissue.
Improper latch-on is painful only during feedings.
Eczema isolated to the nipple, while a reasonable part of the differential, would be much more unusual.
A 50-year-old male presents to your office with erythroderma and fever. He has not had a sore throat, rhinorrhea, cough, or urinary tract symptoms. His current medications include lisinopril (Prinivil, Zestril), atenolol (Tenormin), and allopurinol (Zyloprim). On examination he has a blood pressure of 110/90 mm Hg, a pulse rate of 90 beats/min, and a temperature of 38.6°C (101.5°F). The skin is remarkable for marked erythema over 90% of the body, with tenderness to touch. His mental status is clear and his neck is supple. Mildly tender adenopathy is noted in the neck, axillae, and groin. He has no oral ulcerations or ocular symptoms.
A CBC shows a WBC count of 15,000/mm3 (N 4300–10,800) with 20% eosinophils. A metabolic profile shows an AST (SGOT) level of 100 U/L (N 10–40) and an ALT (SGPT) level of 110 U/L (N 10–55), but is otherwise normal.
Which one of the following is the most likely diagnosis?
A. Stevens-Johnson syndrome
B. Erysipelas
C. Red man syndrome
D. Toxic shock syndrome
E. Drug reaction with eosinophilia and systemic symptoms (DRESS syndrome)
E
The hallmark of DRESS syndrome is erythroderma accompanied by fever, lymphadenopathy, elevation of liver enzymes, and eosinophilia. The offending medication should be discontinued immediately and treatment with corticosteroids should be initiated. Seizure medications such as carbamazepine, phenytoin, lamotrigine, and phenobarbital are responsible for approximately one-third of cases. Allopurinol-associated DRESS syndrome has the highest mortality rate.
A 21-year-old white female presents to the emergency department with a history consistent with a lateral ankle sprain that occurred 2 hours ago while she was playing softball. She complains of pain over the distal anterior talofibular ligament, but is able to bear weight. There is mild swelling, mild black and blue discoloration, and moderate tenderness to palpation over the insertion of the anterior talofibular ligament, but the malleoli are nontender to palpation. Which one of the following statements is true regarding the management of this case? (check one)
A. Anteroposterior, lateral, and 30 degrees internal oblique (mortise view) radiographs should be done to rule out fracture
B. Stress radiographs will be needed to rule out a major partial or complete ligamentous tear
C. The patient should use crutches and avoid weight bearing for 10–14 days
D. Early range-of-motion exercises should be initiated to maintain flexibility
E. For best results, functional rehabilitation should begin within the first 24 hours after injury
D
This patient has an uncomplicated lateral ankle sprain and requires minimal intervention. The Ottawa ankle rules states that ankle radiographs should be done if the patient has pain at the medial or lateral malleolus and either bone tenderness at the back edge or tip of the lateral or medial malleolus, or an inability to bear weight immediately after the injury or in the emergency department, or both.
Sprains can be differentiated from major partial or complete ligamentous tears by AP, Lat, and 30˚ internal oblique (mortise view) xrays. If the joint cleft between either malleolus and the talus is >4 mm, a major ligamentous tear is probable.
Stress radiographs in forced inversion are sometimes helpful to demonstrate stability, but ankle instability can be present with a normal stress radiograph. Grade I and II ankle sprains are best treated with RICE (rest, ice, compression, elevation) and an air splint for ambulation. NSAIDs are used for control of pain and inflammation. Heat should not be applied. Early range-of-motion exercises should be initiated to maintain flexibility. Weight bearing is appropriate as tolerated and functional rehabilitation should be started when pain permits. Exercises on a balance board will help develop coordination.
Uterine rupture is a potential complication of attempted vaginal birth after cesarean (VBAC). The most reliable indication that uterine rupture may have occurred is: (check one)
A. Cessation of uterine contractions during active labor
B. Fetal bradycardia
C. Vaginal bleeding
D. Sudden lower abdominal pain
E. Maternal hypotension
B
Uterine rupture occurs in 0.2%–1.0% of women in labor after one previous low transverse cesarean section. Uterine pain, cessation of contractions, vaginal bleeding, failure of labor to progress, or fetal regression may occur, but none of these are as consistent as fetal bradycardia in cases of uterine rupture during labor for VBAC patients.
A 22-year-old male with no previous history of shoulder problems is injured in a fall. He has immediate pain and is unable to abduct his arm. You examine him and order an MRI, which reveals an acute tear of the rotator cuff. Which one of the following is the best initial treatment for this injury? (check one)
A. Observation without treatment for 1 month
B. Immobilization for 1 month
C. Physical therapy for 1 month
D. Corticosteroid injection
E. Surgical repair
E
An acute rupture of any major tendon should be repaired asap. Acute tears of the rotator cuff should be repaired within 6 weeks of the injury if possible. Nonsurgical management is not recommended for active persons. Observing for an extended period will likely lead to retraction of the detached tendon, possible resorption of tissue, and muscle atrophy
Cilostazol (Pletal) has been found to be a useful drug for the treatment of intermittent claudication. This drug is contraindicated in patients with: (check one)
A. Congestive heart failure
B. A past history of stroke
C. Diabetes mellitus
D. Third degree heart block
E. Hyperlipidemia
A
Cilostazol is a drug with phosphodiesterase inhibitor activity introduced for the symptomatic treatment of arterial occlusive disease and intermittent claudication.
Cilostazol should be avoided in patients with CHF. There are no limitations on its use in patients with previous stroke or a history of diabetes.
It has been found to have beneficial effects on HDL cholesterol levels and in the treatment of third degree heart block.
A 22-year-old primigravida presents for routine prenatal care at 18 weeks gestation. She is frustrated because of increased pigmentation on her face consistent with melasma (chloasma). Which one of the following would you recommend for this patient?
A. Use of a high-potency broad-spectrum sunscreen
B. Use of hydroquinone for 4 weeks
C. Postpartum use of oral contraceptives
D. Avoiding future use of topical retinoids
E. Increased surveillance for skin cancer beginning at age 40
A
Melasma - due to hyperpigmentation related to normal hormonal changes that accompany pregnancy; can also be caused by oral contraceptives and is more common in dark-skinned persons. High-potency broad-spectrum sunscreens may help prevent melasma, or at least prevent worsening of the condition. Topical retinoids, hydroquinone, and corticosteroids can also be helpful, but are usually reserved for postpartum use and require months of treatment.
Other treatments include azelaic acid, chemical peels, kojic acid, cryosurgery, and laser treatment. Melasma usually improves spontaneously after delivery, but it may be prolonged or worsened by oral contraceptive use. It does not increase the risk of developing skin malignancies.
You have hospitalized a 67-year-old obese white female for urosepsis. She has completed a course of intravenous antibiotics. She has hypertension, diabetes mellitus, and congestive heart failure. In addition, she has renal failure which has worsened, and she has been on hemodialysis for 1 week. The chart lists her medications as enalapril (Vasotec), furosemide (Lasix), labetalol (Trandate, Normodyne), insulin, and heparin for flushing intravenous lines. For the past 2 days she has had nosebleeds. A CBC is normal except for mild anemia and marked thrombocytopenia of 28,000/mL. Which one of the following is most likely the cause of her thrombocytopenia? (check one)
A. Enalapril
B. Furosemide
C. Labetalol
D. Insulin
E. Heparin
E
A number of medications can cause thrombocytopenia, but heparin is a more likely cause than enalapril, furosemide, labetalol, or insulin. Even the small doses of heparin used to flush intravenous lines can be a source of thrombocytopenia
A new first-time mother calls for advice on nipple pain with breastfeeding. She is 6 days post partum after an uncomplicated delivery.
Which one of the following would be most effective?
A. Lanolin cream
B. Expressed breast milk
C. Tea bag compresses
D. Hydrogel dressing
E. Education on positioning
E
Nipple pain with breastfeeding is extremely common, with some studies reporting a prevalence of up to 96%. The best intervention for nipple pain is education on proper positioning and attachment of the infant.
Topical remedies may also be effective, although no one topical agent has been shown to be clearly superior, and none is as effective as education on positioning and latch-on.
Which one of the following has been shown to reduce the croup score in children and lead to shorter hospital stays? (check one)
A. Dexamethasone (Decadron), 0.6 mg/kg in a single oral dose
B. Amoxicillin, 45 mg/kg/day divided into two doses, for 10 days
C. Azithromycin (Zithromax), 10 mg/kg the first day, then 5 mg/kg daily for 4 days
D. Albuterol (Ventolin), 0.63 mg by aerosol every 4 hours
E. Ceftriaxone (Rocephin), 50 mg/kg intramuscularly in a single dose
A
Croup is a viral illness and is not treated with antibiotics. Oral or intramuscular dexamethasone, 0.6 mg/kg as a single dose, and nebulized budesonide have been shown to reduce croup scores and shorten hospital stays.
Racemic epinephrine may be used acutely, but rebound can occur. Albuterol has not been shown to be helpful.
A 56-year-old female has a 35-pack-year smoking history. She is concerned that she may have COPD, although she has no history of chronic cough, chest pain, or other pulmonary symptoms. Her family history is remarkable for a mother with COPD who was a smoker, but there is no family history of α1-antitrypsin disease.
Which one of the following would you recommend with regard to screening spirometry?
A. Screening, based on her age
B. Screening, based on her family history
C. Screening, based on her smoking history
D. No screening, based on lack of benefit
D
COPD diagnosis is made by documenting airflow obstruction in the presence of symptoms and/or risk factors. Airflow limitation cannot be accurately predicted by the history and examination.
The USPSTF concluded that there is “moderate certainty” that screening asymptomatic patients for COPD using spirometry has little or no benefit and is not recommended.
The condition shown in Figure 4 occurred in a 31-year-old sexually active male. Which one of the following is true regarding this problem?
A. Diagnosis by biopsy and viral typing is recommended
B. Acetowhite staining is indicated to accurately map margins prior to treatment
C. Treatment with 5% fluorouracil cream (Efudex) is effective and safe
D. Treatment has a favorable impact on the incidence of cervical and genital cancer
E. HPV testing is indicated for this patient’s sexual partners
E
Genital warts are typically caused by HPV types 6 / 12, which are rarely associated with invasive squamous cell carcinoma. In general, chemical treatments are more effective on soft, moist, nonkeratinized genital lesions, while physical ablative treatments are more effective for keratinized lesions.
Diagnosis by biopsy and viral typing is no longer recommended.
Acetowhite staining has not been shown to favorably affect the course or treatment of HPV-associated genital warts.
Topical 5% fluorouracil cream has been associated with severe local reactions and teratogenicity, and is no longer recommended.
Treatment of genital warts has not been shown to reduce the incidence of cervical or genital cancer.
Which one of the following is appropriate treatment for asymptomatic chlamydial infection during the second trimester of pregnancy? (check one)
A. Azithromycin (Zithromax)
B. Doxycycline
C. Metronidazole (Flagyl)
D. Levofloxacin (Levaquin)
A
Several clinical trials suggest that 7-day regimens of erythromycin or amoxicillin, or single-dose regimens of azithromycin, are effective for treating chlamydial infections during pregnancy.
Doxycycline and levofloxacin are contraindicated during pregnancy due to potential ill effects on the fetus,
metronidazole is not effective for the treatment of chlamydial infections.
Which one of the following has the best evidence of effectiveness for preventing fractures in postmenopausal women with osteoporosis? (check one)
A. Home-hazard assessment
B. Daily supplementation with vitamin D
C. Treatment with calcitonin
D. Treatment with alendronate (Fosamax)
D
Of the options listed, treatment with bisphosphonates to prevent osteoporotic hip and vertebral fractures is the only one supported by consistent patient-oriented, high-quality clinical evidence.
While each of the other recommendations has merit, the overall level of evidence for effectiveness is less compelling for these treatments than for treatment with bisphosphonates
A 65-year-old white female develops a burning pain in the left lateral thorax, followed 2 days later by an erythematous vesicular rash. Of the following, the best treatment is: (check one)
A. Topical corticosteroids
B. Oral corticosteroids
C. Topical acyclovir (Zovirax)
D. Oral valacyclovir (Valtrex)
E. Topical capsaicin (Zostrix)
D
The treatment of choice for acute herpes zoster is oral antiviral agents. Acyclovir, valacyclovir, and famciclovir have all been shown to be efficacious with 7 days of oral treatment. Studies suggest that valacyclovir may be superior to acyclovir in decreasing both acute and postherpetic pain. Famciclovir appears to be equal in efficacy to valacyclovir. Topical acyclovir may be effective for more limited forms of herpes simplex, but is usually not effective for herpes zoster.
A 54-year-old female presents with a complaint of dizziness. Two days ago, while riding in a friend’s car and trying to read a book, she experienced sudden extreme nausea and a “spinning” feeling that lasted for 20 minutes. She also had a headache that mainly felt like a fullness in the area around her left ear. Since then she has had only mild dizziness when she moves her head too quickly. She recalls experiencing these symptoms on two other occasions but cannot remember the circumstances, although she thinks one episode may have been related to having had too much caffeine.
A review of systems is positive for a humming in her ears over the last few years. On examination both ears appear normal. Mild horizontal nystagmus can be seen on movement of the head to the left. Audiograms are normal in the right ear, with a low-frequency hearing loss on the left.
Which one of the following is the most likely diagnosis? (check one)
A. Motion sickness
B. Meniere’s disease
C. Vestibular migraine
D. Benign positional vertigo
B
Meniere’s disease, which is characterized by multiple episodes of vertigo lasting for 20–120 minutes, accompanied by a fluctuating hearing loss, tinnitus, and a sense of aural fullness. Audiograms will reveal a low-frequency hearing loss with an upsloping curve, which can become flattened over the years. Most patients develop unilateral symptoms, with progression to bilateral disease after many years after the onset of the unilateral symptoms. There is often a family history of Meniere’s disease, and there is frequently an association with allergies. The condition can also get worse with caffeine use.
Benign positional vertigo is very common, and hearing loss could be an incidental finding. However, the most common form of age-related hearing loss is seen at the higher frequencies. Positional vertigo like this patient has is common between attacks of Meniere’s disease.
A hospitalized 55-year-old male has developed the tachyarrhythmia shown in Figure 6. He is alert and denies chest pain, although he complains of palpitations and is mildly dyspneic since the onset of this sustained dysrhythmia. His blood pressure is 116/76 mm Hg and pulse oximetry shows 93% saturation on 2L of oxygen.Which one of the following would be the best treatment for this patient?
A. Synchronized DC cardioversion
B. Metoprolol (Lopressor)
C. Amiodarone (Cordarone)
D. Adenosine (Adenocard)
E. Atropine
D
The patient has paroxysmal supraventricular tachycardia (PSVT) with a heart rate of approximately 170 beats/min. IV adenosine is the treatment of choice for PSVT.
Because the patient is hemodynamically stable, DC cardioversion is not indicated. Metoprolol may slow the heart rate but likely will not convert it to sinus rhythm. Amiodarone is indicated for hemodynamically stable ventricular tachycardia. Atropine is contraindicated in this or any other tachyarrhythmia.
You are evaluating a 5-month-old with fever, tachypnea, and mild respiratory distress in the emergency department. You hear mild basilar rales. The child does not appear toxic. Which one of the following tests would be the most appropriate as an initial study? (check one)
A. A chest radiograph
B. A CBC
C. A C-reactive protein level
D. Oxygen saturation by pulse oximetry
D
Pulse oximetry should be obtained on ALL pediatric patients with significant tachypnea, pallor, or respiratory distress.
It has been found that CBCs, CRP, and ESR are not effective in differentiating between viral and bacterial pneumonia. CXR are also ineffective in distinguishing viral and bacterial pneumonia, and should be obtained in cases of ambiguous clinical findings, prolonged pneumonia, and pneumonia that is unresponsive to antibiotic therapy, as well as when there is the possibility of complications such as pleural effusions.
Which one of the following is true concerning the treatment of tobacco use? (check one)
A. Tobacco withdrawal symptoms abate in 3 days
B. Physicians’ advice to patients to stop smoking is ineffectual
C. Of all the products available for smoking cessation, only bupropion (Wellbutrin) is consistently effective
D. Nicotine replacement therapy is dangerous for patients with stable angina
E. Nicotine causes physical dependence
E
Nicotine causes both physical dependence and tolerance. Withdrawal from nicotine can last several weeks or months. Physicians’ advice to stop smoking increases the rate of stopping smoking by about 30%. Bupropion is no more or less effective than other products for smoking cessation. Nicotine replacement therapy is safe in patients with stable angina.
A 60-year-old male is referred to you by his employer for management of his hypertension. He has been without primary care for several years due to a lapse in insurance coverage. During a recent employee health evaluation, he was noted to have a blood pressure of 170/95 mm Hg. He has a 20-year history of hypertension and suffered a small lacunar stroke 10 years ago. He has no other health problems and does not smoke or drink alcohol. A review of systems is negative except for minor residual weakness in his right upper extremity resulting from his remote stroke. His blood pressure is 168/98 mm Hg when initially measured by your nurse, and you obtain a similar reading during your examination.
In addition to counseling him regarding lifestyle modifications, which one of the following is the most appropriate treatment for his hypertension? (check one)
A. An angiotensin receptor blocker
B. A β-blocker
C. A calcium channel blocker
D. A thiazide diuretic/ACE inhibitor combination
E. No medication
D
This patient has stage 2 hypertension, and his history of stroke is a compelling indication to use specific classes of antihypertensives. For patients with a history of previous stroke, combination therapy with a diuretic and an ACE inhibitor is indicated, as this combination has been clinically shown to reduce the risk of recurrent stroke.
A 70-year-old retired engineer who is an avid runner asks you about his slow, progressive decrease in exercise performance. He says he realizes he is getting older, but is in good health and is curious as to why this is happening.
You tell him that there are multiple physiologic changes associated with aging that lower exercise performance, including a decrease in: (check one)
A. cardiac output
B. systolic blood pressure
C. pulse pressure
D. residual lung volume
A
Cardiovascular changes associated with aging include decreased CO, maximum HR, and SV, as well as increased SBP and DBP.
Respiratory changes include an increase in residual lung volume and a decrease in vital capacity.
Other changes include decreases in nerve conduction, proprioception and balance, maximum O2 uptake, bone mass, muscle strength, and flexibility. Most of these changes, however, can be reduced in degree by a regular aerobic and resistance training program.
Which one of the following is most commonly implicated in interstitial nephritis? (check one)
A. NSAIDs
B. ACE inhibitors
C. Diuretics
D. Corticosteroids
E. Antibiotics
E
Antibiotics, especially penicillins, cephalosporins, and sulfonamides, are the most common drug-related cause of acute interstitial nephritis. Corticosteroids may be useful for treating this condition. The other drugs listed may cause renal injury, but not acute interstitial nephritis.
An asymptomatic 55-year-old male visits a health fair, where he has a panel of blood tests done. He brings the results to you because he is concerned about the TSH level of 12.0 µU/mL (N 0.45-4.5). His free T4 level is normal. Which one of the following is most likely to be associated with this finding? (check one)
A. Atrial fibrillation
B. Reduced bone density
C. Systolic heart failure
D. Elevated LDL cholesterol
E. Type 2 diabetes mellitus
D
With subclinical thyroid dysfunction, TSH is either below or above the normal range, free T3 or T4 levels are normal, and the patient has no symptoms of thyroid disease.
- Subclinical hypOthyroidism (TSH >10 µU/mL) is likely to progress to overt hypothyroidism, and is associated with increased LDL cholesterol.
- Subclinical hypERthyroidism (TSH
Neither type of subclinical thyroid dysfunction is associated with diabetes mellitus. There is insufficient evidence of benefit to warrant early treatment of either condition.
You see a 90-year-old male with a 5-year history of progressive hearing loss. The most common type of hearing loss at this age affects: (check one)
A. predominantly high frequencies
B. predominantly mid frequencies
C. predominantly low frequencies
D. all frequencies roughly the same
A
In the geriatric population, presbycusis is the most common cause of hearing loss. Patients typically have the most difficulty hearing higher-frequency sounds such as consonants. Lower-frequency sounds such as vowels are preserved.
Which one of the following is the most effective initial treatment of head lice in an 8-year-old child? (check one)
A. Lindane (Kwell)
B. Wet combing every 4 days, to continue for 2 weeks after any louse is found
C. Head shaving
D. Nightly application of petrolatum to the scalp, covered by a shower cap
E. Malathion (Ovide)
E
Malathion is currently the most effective treatment for head lice and is less toxic than lindane. Permethrin and pyrethrins are less effective than malathion, although they are acceptable alternatives. These insecticides, as well as lindane, are not recommended in children 2 years of age or younger. Wet combing may be effective, but is less than half as effective as malathion. Head shaving is only temporarily effective and is traumatic. Petrolatum is not proven to be effective.
A 24-year-old female with a 2-year history of dyspnea on exertion has been diagnosed with exercise-induced asthma by another physician. Which one of the following findings on pulmonary function testing would raise concerns that she actually has vocal cord dysfunction? (check one)
A. A good response to an inhaled β-agonist
B. Flattening of the inspiratory portion of the flow-volume loop, but a normal expiratory phase
C. Flattening of the expiratory portion of the flow-volume loop, but a normal inspiratory phase
D. Flattening of both the inspiratory and expiratory portion of the flow-volume loop
E. A decreased FEV1 and a normal FVC
B
The diagnosis of vocal cord dysfunction should be considered in patients diagnosed with exercise-induced asthma who do not have a good response to β-agonists before exercise. Pulmonary function testing with a flow-volume loop typically shows a normal expiratory portion but a flattened inspiratory phase.
Sounds from the vocal cords can be very INSPIRING, but if there is vocal cord dysfunction, the INSPIRATORY effect is gone
A 55-year-old white female presents with redness at the scar from a lumpectomy performed for stage I cancer of her right breast 4 months ago. The patient has completed radiation treatments to the breast. She is afebrile and there is no axillary adenopathy. There is no wound drainage, crepitance, or bullous lesions. Which one of the following organisms would be the most likely cause of cellulitis in this patient? (check one)
A. Non-group A Streptococcus
B. Pneumococcus pneumoniae
C. Clostridium perfringens
D. Escherichia coli
E. Pasteurella multocida
A
Cellulitis in patients after breast lumpectomy is thought to be related to lymphedema. Axillary dissection and radiation predispose to these infections. Non–group A hemolytic Streptococcus is the most common organism associated with this infection. The onset is often several weeks to several months after surgery.
Pneumococcus is more frequently a cause of periorbital cellulitis. It is also seen in patients who have bacteremia with immunocompromised status. Immunocompromising conditions would include diabetes mellitus, alcoholism, lupus, nephritic syndrome, and some hematologic cancers.
Clostridium and Escherichia coli are more frequently associated with crepitant cellulitis and tissue necrosis.
Pasteurella multocida cellulitis is most frequently associated with animal bites, especially cat bites.
A 65-year-old white female presents with weight loss and fatigue. On examination, she has lymphadenopathy, hepatomegaly, and mild splenomegaly. Her hemoglobin level is 9.0 g/dL (N 12.0–16.0), and a chemistry panel reveals a serum protein level of 9.0 g/dL (N 6.0–8.0). You order a chest radiograph, which shows clear lung fields and no evidence of lytic lesions in the thoracic spine. Serum protein electrophoresis reveals a monoclonal gamma-globulin spike, which on immunoelectrophoresis is found to be due to IgM kappa-protein. Urine for Bence-Jones protein is positive. A bone marrow biopsy from the iliac crest demonstrates hypercellularity, with a large number of lymphocytes, but normal-appearing plasma cells. Which one of the following is the most likely diagnosis? (check one)
A. Multiple myeloma
B. Waldenström’s macroglobulinemia
C. Sarcoidosis
D. Monoclonal gammopathy of undetermined significance
E. Non-Hodgkin’s lymphoma
B
The patient has Waldenström’s macroglobulinemia - due to an uncontrolled proliferation of lymphocytes and plasma cells, which produce IgM proteins with kappa light chains. The average age at the time of diagnosis is 65 years. Weakness, fatigue, weight loss, bleeding, and recurrent infections are common presenting symptoms. Physical findings include pallor, hepatosplenomegaly, and lymphadenopathy. Typical laboratory findings include moderate anemia and monoclonal IgM peaks on serum electrophoresis. Bence-Jones protein is seen in 80% of cases, but is typically absent in MGUS.
Unlike in multiple myeloma, lytic bone lesions are not seen, and marrow biopsy reveals mostly lymphocytes.
Sarcoidosis usually presents with hilar lymphadenopathy and a polyclonal gammopathy.
Non-Hodgkin’s lymphoma presents with similar symptoms, lymphadenopathy, and hepatosplenomegaly, but generally lacks a monoclonal gammopathy and Bence-Jones proteinemia, and has distinctive malignant lymphocytes on bone marrow biopsy.
A 67-year-old female has a bone density study that indicates a T score of –3.5. You prescribe alendronate (Fosamax) but at her next visit she says she cannot tolerate the side effects and asks about other therapies.
Which one of the following has the best evidence for prevention of both vertebral fractures and hip fractures?
A. Calcitonin-salmon (Miacalcin)
B. Raloxifene (Evista)
C. Teriparatide (Forteo)
D. Zoledronic acid (Reclast)
D
IV zoledronic acid has been shown to reduce both hip fracture risk and vertebral fracture risk.
Teriparatide reduces vertebral fracture risk but not hip fracture risk. The same is true for raloxifene and calcitonin salmon.
You are initiating treatment for a patient being admitted to the hospital with a new diagnosis of pulmonary embolus. Low molecular weight heparin and warfarin (Coumadin) are started immediately.
When can the low molecular weight heparin be stopped? (check one)
A. When the INR is ≥2.0
B. When the INR is ≥2.0 for 24 hours
C. After 4 days, if the INR is ≥ 2.0
D. After 4 days, if the INR has been ≥2.0 for 24 hours
E. After 5 days, if the INR has been ≥2.0 for 24 hours
E
Patients with a PE should be treated with LMWH, unfractionated heparin, or fondaparinux for at least 5 days, and then can be stopped if the INR has been ≥2.0 for at least 24 hours.
Warfarin reduces the activity of coagulation factors II, VII, IX, and X produced in the liver. Coagulation factors produced prior to initiating warfarin remain active for their usual several-day lifespan, which is why LMWH and warfarin must be given concomitantly for at least 5 days.
The INR may reach levels >2.0 before coagulation factors II and X have reached their new plateau levels, accounting for the need for an additional 24 hours of combined therapy before stopping LMWH.
You are writing a prescription for amoxicillin for a 6-year-old female with acute otitis media. Her mother has had an anaphylactic reaction to penicillin in the past and is concerned that she may have passed this trait down to her daughter. You reassure her that this is not usually the case but warn her about potential signs of an allergic reaction. Which one of the following is the most concerning early symptom of a dangerous drug reaction? (check one)
A. Tachycardia and elevated blood pressure
B. Small, bright, erythematous macules diffusely over the trunk
C. Pruritus around the mouth and on the palms of the hands and soles of the feet
D. Eczematous patches in the antecubital and popliteal fossae
E. Diarrhea with blood on the tissue paper
C
Severe type I hypersensitivity reactions are often referred to as anaphylaxis and are the most likely to be life threatening with very little warning.
Anaphylactic reactions result from a massive release of histamine and start with pruritus around the mouth, on the scalp, and on the palms and soles; flushing of the face and neck, with rhinitis and conjunctivitis; angioedema of the oral mucosa, especially of the pharynx and larynx; severe urticaria; dyspnea and bronchospasm (especially in known asthmatics); and hypotension.
A delay in lifesaving therapy during this phase will result in full shock, hypotension, and death.
Type IV reactions usually result in benign, diffuse erythematous macules on the trunk and proximal extremities, often referred to as a drug rash. These reactions infrequently become more severe and rarely are life threatening. In severe cases the lesions become painful and palpable, and may involve blistering, mucositis, and ecchymosis.
A 40-year-old male respiratory therapist presents for a health examination prior to hospital employment. His history indicates that as a child he lived on a farm in Iowa, and his examination is unremarkable, but a chest radiograph shows that both lung fields have BB-sized calcifications in a miliary pattern. No other findings are noted. A PPD skin test is negative. The findings in this patient are most likely a result of (check one)
A. HIV infection
B. histoplasmosis
C. coccidioidomycosis
D. tuberculosis
E. cryptococcosis
B
Asymptomatic patients in excellent health often present with this characteristic chest radiograph pattern, which is usually due to histoplasmosis infection, especially if the patient has been in the midwestern United States. Exposure to bird or bat excrement is a common cause, and treatment is usually not needed.
This pattern is not characteristic of the other infections listed, although miliary tuberculosis is a remote possibility in spite of the negative PPD skin test.
A 32-year-old mail presents to an urgent care center with a 2-day history of left calf pain and swelling, which started gradually a few hours after he played tennis. He remembers that he “tweaked” his calf on a serve late in the match but was able to continue playing. He has no history of prior medical problems, and no recent surgery or immobilization.
On examination his left calf appears slightly erythematous and swollen from the mid-calf to the ankle, with 1+ pitting over the lower leg. There is no venous distention. The left calf is 3 cm greater in circumference than the right calf. He has pain with dorsiflexion, and there is an area of tenderness in the medial calf.
Which one of the following is the most appropriate next step in ruling out deep vein thrombosis in this patient? (check one)
A. D-dimer
B. Ultrasonography
C. Venography
D. Impedance plethysmography
A
A number of pretest probability scoring systems are available for assessing venous thromboembolism (VTE), which includes DVT and PE. Wells Rule divides patients suspected of having a DVT into low, intermediate, and high-risk categories, with a 5%, 17%, and 53% prevalence of DVT, respectively. This patient has a Wells score of 0 (+1 for calf circumference increase >3 cm, +1 for pitting edema, –2 for a likely alternative diagnosis of gastrocnemius strain) and is therefore at low risk. A negative D-dimer assay has a high negative predictive value for DVT, so the diagnosis can be ruled out in a patient who has a low pretest probability and a negative D-dimer result. A negative D-dimer assay does not rule out DVT in a patient with a moderate to high pretest probability
An 82-year-old resident of a local nursing home is brought to your clinic with fever, difficulty breathing, and a cough productive of purulent sputum. The patient is found to have an oxygen saturation of 86% on room air and a chest radiograph shows a new infiltrate. A decision is made to hospitalize the patient.
Which one of the following intravenous antibiotic regimens would be most appropriate for this patient? (check one)
A. Levofloxacin (Levaquin)
B. Ceftriaxone (Rocephin) and azithromycin (Zithromax)
C. Ceftazidime (Fortaz, Tazicef) and levofloxacin
D. Ceftazidime and vancomycin
E. Ceftazidime, levofloxacin, and vancomycin
E
. Nursing-home patients who are hospitalized for pneumonia should be started on intravenous antimicrobial therapy, with empiric coverage for methicillin-resistant Staphylococcus aureus (MRSA) and Pseudomonas aeruginosa. Combination therapy consisting of an
- antipseudomonal cephalosporin such as cefepime or ceftazidime
- antipseudomonal carbapenem such as imipenem or meropenem
- extended-spectrum β-lactam/β-lactamase inhibitor such as piperacillin/tazobactam
PLUS
- antipseudomonal fluoroquinolone such as levofloxacin or ciprofloxacin
- aminoglycoside such as gentamicin, tobramycin, or amikacin
PLUS
- anti-MRSA agent (vancomycin or linezolid)
Ceftriaxone and azithromycin or levofloxacin alone would be reasonable treatment options for a patient with nursing home–acquired pneumonia who does not require hospitalization.
A 34-year-old white male letter carrier has developed progressively worsening dysphagia for liquids and solids over the past 3 months. He says that he has lost about 30 lb during that time. On examination, you note that he is emaciated and appears ill. His pulse rate is 98 beats/min, temperature 37.8°C (100.2°F), respiratory rate 24/min, and blood pressure 95/60 mm Hg. His weight is 45 kg (99 lb) and his height is 170 cm (67 in). His dentition is poor, and there is evidence of oral thrush. His mucous membranes are dry.
You palpate small posterior cervical and axillary nodes. The heart, lung, and abdominal examinations are normal. You promptly consult a gastroenterologist, who performs upper endoscopy, which reveals numerous small ulcers scattered throughout the esophagus with otherwise normal mucosa.
As you continue to investigate, you take a more detailed history. Which one of the following is most likely to be related to the patient’s problem?
A. Intravenous drug use
B. A family history of esophageal cancer
C. Chest pain relieved by nitroglycerin
D. Recent travel to Russia
A
A young man with weight loss, oral thrush, lymphadenopathy, and ulcerative esophagitis is likely to have HIV infection. IVDU is responsible for over a quarter of HIV infections in the United States. Esophageal disease develops in more than half of all patients with advanced infection during the course of their illness. The most common pathogens causing esophageal ulceration in HIV-positive patients include Candida, herpes simplex virus, and cytomegalovirus. Identifying the causative agent through culture or tissue sampling is important for providing prompt and specific therapy
A 55-year-old female receives a gynecologic and breast examination from a nurse practitioner, who also orders a routine mammogram. Who is legally responsible for ensuring that the patient is notified of the results of the mammogram? (check one)
A. The nurse practitioner
B. The supervising physician
C. The facility performing the mammogram
D. The patient
C
While it is certainly appropriate for the nurse practitioner or physician who ordered the test to notify the patient of mammography results, the facility performing the test is legally responsible.
What is the specific antidote used to treat methanol poisoning? (check one)
A. Ethanol
B. Haloperidol
C. Lorazepam (Ativan)
D. Naloxone
E. Thiamine
A
The current management of methanol intoxication, depending on its severity, includes ethanol administration to inhibit the metabolism of methanol, hemodialysis to remove alcohol and its toxins, and vigorous management of metabolic acidosis with bicarbonate therapy. Ethanol is a competitive inhibitor of toxin metabolism and slows the formation of toxic metabolites, formaldehyde, and formic acid from methanol, permitting these products to be disposed of by ordinary metabolic or excretory pathways. It has a similar effect in ethylene glycol poisoning, slowing the formation of glycoaldehyde and glycolic, glyoxylic, and oxalic acids.
A 60-year-old male presents to the urgent care center with a fever and a productive cough. He has a 40 pack/year history of cigarette smoking. In addition to lobar pneumonia on a chest radiograph, there is an incidental finding of bilateral pleural plaques. Which one of the following is the most likely cause of this finding? (check one)
A. Coal dust
B. Silicon dust
C. Asbestos
D. Vinyl chloride
E. Radon
C
Development of pleural plaques is the most common pathologic pulmonary response to asbestos inhalation. Over time, collagen is deposited in the pleura and may calcify. Most plaques are asymptomatic, and there is no evidence that plaques transform into malignant lesions. This should alert the physician to follow the patient for development of more serious asbestos-related diseases (e.g., lung cancer and mesothelioma).
You discover a 10-cm enlarging hematoma adjacent to the episiotomy site in a patient whose baby you delivered 6 hours ago. The best management at this time is: (check one)
A. A perineal pad and cold compresses
B. Removal of the sutures and clots, and reclosure
C. Hypogastric artery ligation
D. Needle aspiration of the hematoma
B
Enlarging postpartum hematomas adjacent to an episiotomy are best treated by removing the sutures and ligating the specific bleeding sites.
A perineal pad and cold compresses are inadequate for an enlarging lesion, and hypogastric artery ligation and hysterectomy are indicated only with supravaginal hematomas.
Which one of the following hospitalized patients is the most appropriate candidate for thromboembolism prophylaxis with enoxaparin (Lovenox)? (check one)
A. An ambulatory 22-year-old obese male admitted for an appendectomy
B. A 48-year-old male with atrial fibrillation on chronic therapeutic anticoagulation, admitted for cellulitis
C. A 48-year-old male with end-stage liver disease and coagulopathy
D. A 52-year-old female on chronic estrogen therapy, admitted with severe thrombocytopenia
E. A 67-year-old female with hemiparesis, admitted for community-acquired pneumonia
E
Prophylaxis is generally recommended for patients over the age of 40 who have limited mobility for 3 days or more and have at least one of the following risk factors: acute infectious disease, New York Heart Association class III or IV heart failure, acute myocardial infarction, acute respiratory disease, stroke, rheumatic disease, inflammatory bowel disease, previous venous thromboembolism, older age (especially >75 years), recent surgery or trauma, immobility or paresis, obesity (BMI >30 kg/m2), central venouscatheterization, inherited or acquired thrombophilic disorders, varicose veins, or estrogen therapy.
Pharmacologic therapy with an anticoagulant such as enoxaparin is clearly indicated in the 67-year-old who has limited mobility secondary to hemiparesis and is being admitted for an acute infectious disease.
The patient on chronic anticoagulation, the patient with severe thrombocytopenia, and the patient with coagulopathy are at high risk for bleeding if given anticoagulants, and are better candidates for nonpharmacologic therapies such as foot extension exercises, graduated compression stockings, or pneumatic compression devices.
Although the 22-year-old is obese and recently had surgery, his young age and ambulatory status make anticoagulant prophylaxis less necessary.
An 82-year-old male presents to your office because his blood pressure has been “high” when taken by a friend on several occasions. His blood pressure in your office is 173/94 mm Hg, which is similar to the levels his friend recorded. The history and physical examination are otherwise unremarkable, and a CBC, metabolic panel, and urinalysis are normal. Which one of the following is most consistent with current evidence?
A. This patient’s mortality will not be affected by treatment of his hypertension
B. Treating this patient with an ARB for hypertension would be ineffective and dangerous
C. Treatment with a thiazide diuretic will lower this patient’s risk of death
D. In this age group, treatment of hypertension in males does not reduce stroke and heart failure as it does in females
C
Studies have shown that the treatment of systolic and diastolic hypertension, especially with thiazide diuretics, with or without an ACE inhibitor, reduces stroke, heart failure, and death from all causes. Such treatment is effective in both sexes.
The best available evidence supports which one of the following statements regarding the cardiovascular effects of hypoglycemic agents? (check one)
A. Sulfonylureas increase cardiovascular events
B. Metformin (Glucophage) reduces cardiovascular mortality rates
C. Incretin mimetics reduce the risk of cardiovascular events
D. α-Glucosidase inhibitors have no effect on cardiovascular events
B
Metformin is the only hypoglycemic agent shown to reduce mortality rates in patients with type 2 DM.
A recent systematic review concluded that cardiovascular events are neither increased nor decreased with the use of sulfonylureas.
The effect of incretin mimetics/enhancers on cardiovascular events has not been determined.
The STOP-NIDDM study suggests that α-glucosidase inhibitors reduce the risk of cardiovascular events in patients with impaired glucose tolerance.
A patient with chronic kidney disease presents with chronic normocytic anemia with a hemoglobin level of 7.8 g/dL. The best outcome is predicted if you raise the hemoglobin level to: (check one)
A. 8–10 g/dL
B. 10–12 g/dL
C. 12–14 g/dL
D. >14 g/dL
B
have shown that patients who had hemoglobin levels targeted to normal ranges did worse than patients who had hemoglobin levels of 10–12 g/dL. The incidence of stroke, heart failure, and death increased in patients targeted to normal hemoglobin levels, and there was no demonstrable decrease in cardiovascular events
Which one of the following interpretations of Figure 5 is most accurate?
A. Surgical menopause is on the increase
B. Menopause is occurring at an earlier age
C. The mean age for reaching menopause is 50
D. One hundred percent of this sample reached menopause by age 60
E. Menopause is the result of relative estrogen deficiency
D
In the figure shown, only one of the listed conclusions can be inferred: 100% of the sample selected reached menopause by age 60. This does not imply that all women reach menopause by age 60. No conclusions regarding the plausible causes of menopause, surgical or hormonal, are valid on the basis of this graph.
This graph illustrates a skewed, or asymmetric, distribution. Therefore, the mean (arithmetic average) age of menopause is different from the median age or middle value in the sequence from highest to lowest. Whereas the median age of menopause is approximately 50, the mean age is closer to 45, due to the skewing effect of the younger age groups represented.
A 45-year-old female presents to your office with knee pain. She was playing volleyball yesterday when she collided with another player and was unable to continue playing because of pain in her knee. The knee was swollen this morning. She is able to walk but not without pain, and she also has pain when she attempts to bend her knee. On examination there is medial joint line tenderness and a positive Thessaly test.
Which one of the following is the most likely cause of her knee pain? (check one)
A. Osteoarthritis
B. Anterior cruciate ligament tear
C. Collateral ligament tear
D. Medial meniscus tear
E. Tibial plateau fracture
D
A medial meniscus tear is the most likely diagnosis in a patient > 40 who was bearing weight when the injury occurred, was unable to continue the activity, and has a positive Thessaly test (patient stands on one leg and flex the knee to 20°, then internally and externally rotate the knee. The presence of swelling immediately after the injury makes an internal derangement of the knee more likely)
This patient is able to bear weight, so a fracture is also not likely. Either a collateral ligament tear or an anterior cruciate ligament tear is possible, but these are not as common in this situation.
A 45-year-old female presents with a 3-month history of hoarseness that is not improving. She works as a high-school teacher. The most appropriate management at this time would be: (check one)
A. voice therapy
B. azithromycin (Zithromax)
C. a trial of inhaled corticosteroids
D. a trial of a proton pump inhibitor
E. laryngoscopy
E
Hoarseness most commonly affects teachers and older adults. The cause is usually benign, but extended symptoms or certain risk factors should prompt evaluation; specifically, laryngoscopy is recommended when hoarseness does not resolve within 3 months or when a serious underlying cause is suspected.
The American Academy of Otolaryngology/Head and Neck Surgery Foundation guidelines state that antireflux medications should not be prescribed for patients with hoarseness without reflux symptoms
An otherwise healthy 10-year-old female presents with a papulovesicular eruption on one leg.It extends from the lateral buttock, down the posterolateral thigh, to the lateral calf. It is mildly painful. The patient’s immunizations are up to date, including varicella and MMR. Her family has a pet cat at home, and another child at her school was sent home with a rash earlier in the week.
Which one of the following is the most likely diagnosis?
A. Contact dermatitis
B. Herpes zoster dermatitis
C. Tinea corporis
D. Scabies
B
Herpes zoster can occur from either a wild strain or a vaccine strain of varicella-zoster virus in vaccinated children, but the incidence is low. All cases are mild and uncomplicated.
Which one of the following statements regarding varicoceles is true? (check one)
A. Repair of varicoceles usually results in infertility
B. The incidence of varicoceles in adult males is C. Most varicoceles are bilateral
D. Varicoceles usually begin between 5 and 8 years of age
E. A unilateral varicocele on the right side should be referred for further evaluation
E
Most varicoceles appear in adolescence, occur on the left side, and are asymptomatic. About 10% are bilateral. Surgical repair of large varicoceles can reverse testicular growth arrest, with catch-up growth occurring within 1–2 years. Varicoceles are the most common surgically correctable cause of subfertility in men and the goal of surgery is to maximize chances for fertility
A 70-year-old white male presents with fatigue, weakness, and foot paresthesias. His hemoglobin level is 10.5 g/dL (N 12.6–17.4). His peripheral smear is shown in Figure 2.
Which one of the following is the most likely diagnosis? (check one)
A. Iron deficiency anemia
B. Vitamin B12 deficiency anemia
C. Hemolytic anemia
D. Acute myelogenous leukemia
E. Chronic myelogenous leukemia
B
The blood smear shows a hypersegmented polymorphonuclear neutrophil PMN, typical of vitamin B12 deficiency with pernicious anemia. The anemia is of the macrocytic type (MCV >100 μ m ).
There is no evidence of hemolysis or leukemia. While IDA can be a coexisting problem, the hypersegmented PMN is classic for vitamin B12 deficiency. It is important to note that elderly patients with vitamin B12 deficiency may have neurologic signs and symptoms before developing hematologic abnormalities.
You are helping a hospice program manage the symptoms of a 77-year-old male with end-stage colon cancer. He has required increasingly higher doses of his opioid medication to control symptoms of pain and dyspnea.
In this situation, it should be kept in mind that which one of the following adverse effects of opioids does NOT diminish over time? (check one)
A. Constipation
B. Nausea
C. Mental status changes
D. Pruritus
E. Sedation
A
Constipation is one adverse effect of opioid treatment that does not diminish with time. Thus, this effect should be anticipated, and recommendations for prevention and treatment of constipation should be discussed when initiating opioids. Nausea and vomiting, mental status changes, sedation, and pruritus are also common with the initiation of opioid treatment, but these symptoms usually diminish with time, and can be managed expectantly.
For 2 weeks, a 62-year-old male with biopsy-documented cirrhosis and ascites has had diffuse abdominal discomfort, fever, and night sweats. His current medications are furosemide (Lasix) and spironolactone (Aldactone). On examination, his temperature is 38.0° C (100.4° F), blood pressure 100/60 mm Hg, heart rate 92 beats/min and regular. The heart and lung examination is normal. The abdomen is soft with vague tenderness in all quadrants. There is no rebound or guarding. The presence of ascites is easily verified. Bowel sounds are quiet. The rectal examination is normal, and the stool is negative for occult blood. You perform diagnostic paracentesis and send a sample of fluid for analysis. Which one of the following findings would best establish the suspected diagnosis of spontaneous bacterial peritonitis? (check one)
A. pH B. Bloody appearance
C. Neutrophil count >300/mL
D. Positive cytology
E. Total protein >1 g/dL
C
Diagnostic paracentesis is recommended for patients with ascites of recent onset, as well as for those with chronic ascites who present with new clinical findings such as fever or abdominal pain. A neutrophil count >250/mL is diagnostic for peritonitis. Once peritonitis is diagnosed, antibiotic therapy should be started immediately without waiting for culture results.
Bloody ascites with abnormal cytology may be seen with hepatoma, but is not typical of peritonitis.
The ascitic fluid pH does not become abnormal until well after the neutrophil count has risen, so it is a less reliable finding for treatment purposes.
A protein level >1 g/dL is actually evidence against spontaneous bacterial peritonitis.
A 68-year-old Mexican American female is brought to your office by her son with a complaint of headaches. The patient speaks English adequately, but diverts her eyes to look at her son when answering your questions. Which one of the following is the most likely reason for this patient not making eye contact? (check one)
A. Her son is overly controlling
B. She is a victim of abuse
C. She is being untruthful
D. She is showing respect to you
E. She is depressed
D
Nonverbal communication is important for identifying issues that a patient may be hiding or be unwilling to divulge. Some nonverbal clues, however, are culturally biased.
- Many older or less-educated Mexican-Americans consider direct eye contact to be disrespectful. Because a physician is held in high regard, these patients will often either look down or look at another, more equal person in the room while being interviewed.
- Many Americans, on the other hand, may consider a lack of eye contact to be negative, implying that a patient is unsure of the information they are providing, has poor self-esteem, or is hiding something.
A 56-year-old female presents for a health maintenance examination. She has a history of a total hysterectomy for benign disease 4 years ago. You are able to document that the hysterectomy pathology was benign and that she has had normal Papanicolaou (Pap) tests for 10 years. The patient asks about regular Pap smears. Which one of the following would be the most appropriate recommendation? (check one)
A. Routine Pap smears should be continued until age 70
B. A Pap smear should be done every 3 years
C. A Pap smear is not indicated
D. A Pap smear should be done yearly for 3 years and only if indicated thereafter
C
After a hysterectomy for documented benign disease, cytologic screening may be discontinued. Pap smears in this population are low yield and may cause unnecessary testing due to false-positives. Pap smears may be continued if the reason for the hysterectomy is uncertain. If there is a history of invasive cervical cancer or DES exposure, screening should be continued, although there is not a great deal of data to support this practice
A 62-year-old male is admitted to the hospital with acute renal failure. A renal biopsy confirms the diagnosis of acute interstitial nephritis (AIN). Infection and immune-associated causes are ruled out, and you consider medications as a potential cause. Which one of the following would be most likely to cause AIN? (check one)
A. Chronic daily use of metoprolol (Lopressor)
B. Twice-daily use of ibuprofen for 2 weeks
C. Initiation of lisinopril (Prinivil, Zestril) therapy 1 week ago
D. A 5-day course of azithromycin (Zithromax) 6 months ago
E. Intermittent use of acetaminophen, up to 4 g/day
B
Acute interstitial nephritis (AIN) is often drug-induced. Of the medications listed, ibuprofen is the most likely offending agent. Development of AIN usually becomes evident approximately 2 weeks after starting a medication and is not dose-related. Other medications strongly associated with AIN include various antibiotics (particularly cephalosporins, penicillins, sulfonamides, aminoglycosides, and rifampin), diuretics, and miscellaneous medications such as allopurinol.
A 59-year-old male who is morbidly obese suffers a cardiac arrest. Intravenous access cannot be obtained. Which one of the following is true regarding intraosseous drug administration in this patient? (check one)
A. The patient’s age and size are a contraindication to intraosseous administration
B. The time needed to establish intraosseous access is too great
C. Many drugs cannot be administered intraosseously
D. Endotracheal administration is preferred
E. There are no contraindications to intraosseous administration in this patient
E
The AHA-ACLS guidelines state that intraosseous access can be obtained in almost all age groups rapidly, and is preferred over the endotracheal route. Any drug that can be administered IV can be administered intraosseously. Many drugs administered via an endotracheal tube are poorly absorbed, and drug levels vary widely.
Residents of long-term care facilities who have advance directives are more likely to?
A. Be placed on a ventilator
B. Undergo feeding tube placement
C. Be admitted to a hospital
D. Die in a hospital
C
Studies show that few residents have an advance directive at the time of admission to a nursing home. Studies also show that residents with advance directives are more likely to die in a nursing home with hospice care, are less likely to have a feeding tube or ventilator in the last month of life, require fewer resources, and are hospitalized less
A 58-year-old male complains of leg claudication. Subsequent tests reveal that he has significant bilateral peripheral arterial disease. His current medications include atenolol (Tenormin), 50 mg/day, and aspirin, 325 mg/day. His blood pressure is 128/68 mm Hg, and his pulse rate is 64 beats/min. His LDL-cholesterol level is 123 mg/dL. The addition of which one of the following could reduce this patient’s symptoms?
A. Epoetin alfa (Epogen)
B. Nifedipine (Procardia)
C. Simvastatin (Zocor)
D. Testosterone supplementation
E. Warfarin (Coumadin) titrated to an INR of 2.0–3.0
C
Routine exercise up to near-maximal pain on a regular basis has been shown to be one of the most effective treatments for symptoms of PAD. Smoking cessation and aspirin are also standard recommendations, and can both prevent CVEs and slow the rate of progression of PAD symptoms.
Statin drugs (specifically simvastatin and atorvastatin) have been shown to be beneficial for treatment of PAD symptoms and prevention of CVEs through the reduction of cholesterol, but they also appear to have other properties that help reduce leg pain in patients with PAD.
Although lowering abnormally high blood pressure is recommended in PAD patients, only ACEi have been shown to reduce symptoms of PAD directly.
An obese 10-year-old male with tonsillar hypertrophy is brought to your office because of snoring. There is no history of recent or past visits for tonsillitis. Polysomnography shows moderate obstructive sleep apnea syndrome.
Which one of the following is the treatment of choice for this patient?
A. Continuous positive airway pressure
B. Intranasal corticosteroids
C. Extended antibiotic therapy
D. Adenotonsillectomy
D
Childhood obstructive sleep apnea syndrome has a prevalence rate of 5.7%. It is associated with growth, cardiovascular, and neurobehavioral abnormalities. Adenotonsillectomy is the treatment of choice.
Although CPAP can be effective, compliance is poor and it is therefore not a first-line treatment. Intranasal corticosteroids may also be helpful, but the benefit appears small.
Which one of the following fluoroquinolones should NOT be used in the treatment of urinary tract infections? (check one)
A. Ciprofloxacin (Cipro)
B. Gatifloxacin (Tequin)
C. Levofloxacin (Levaquin)
D. Moxifloxacin (Avelox)
E. Norfloxacin (Noroxin)
D
When trimethoprim/sulfamethoxazole is contraindicated, a 3-day course of ciprofloxacin, levofloxacin, norfloxacin, lomefloxacin, or gatifloxacin is a reasonable alternative.
Moxifloxacin attains inadequate urinary concentrations and should not be used in the management of urinary tract infections.
A 72-year-old white male develops a rapidly growing epithelial tumor just in front of his right ear. He states that it began as a firm red papule about 6 weeks ago. It is now 1.5 cm in diameter and has a horny plug in the center.
The most likely diagnosis is: (check one)
A. Bowen’s disease
B. Basal cell carcinoma
C. Keratoacanthoma
D. Kaposi’s sarcoma
E. Seborrheic keratosis
C
Keratoacanthoma is a relatively common lesion in the elderly, but is difficult to distinguish from squamous cell carcinoma. Most keratoacanthomas undergo a benign self-healing course but may leave a large, unsightly scar. Treatment is almost always preferred, both for cosmetic reasons and to prevent the rare case of malignant transformation. Proper treatment for a lesion with this appearance is excisional biopsy in order to distinguish between keratoacanthoma and squamous cell carcinoma.
A cement plant worker presents to your office with the recurrent acute skin eruption on his legs shown in Figure 7. It extends proximally from the dorsum of the feet to just below the knees and is on both legs. This is the third eruption in 2 years.This patient most likely has: (check one)
A. tinea with a secondary id reaction
B. rhus dermatitis
C. methicillin-resistant Staphylococcus aureus (MRSA) cellulitis
D. contact dermatitis related to his occupation
D
Because this dermatitis is recurrent and symmetric, contact dermatitis should be suspected.
Rhus dermatitis is a contact dermatitis, but it is more acute and presents with bullae and vesicles that are more linear than those seen in this patient.
MRSA usually presents as a unilateral cellulitis, or more commonly as inflammatory nodules or pustules.
This dermatitis is not scaling and does not have a distinct border that would suggest tinea.
A 72-year-old male with class III congestive heart failure (CHF) due to systolic dysfunction asks if he can take ibuprofen for his “aches and pains.” Appropriate counseling regarding NSAID use and heart failure should include which one of the following? (check one)
A. NSAIDs are a good choice for pain relief, as they decrease systemic vascular resistance
B. NSAIDs are a good choice for pain relief, as they augment the effect of his diuretic
C. High-dose aspirin (325 mg/day) is preferable to other NSAIDs for patients taking ACE inhibitors
D. NSAIDs, including high-dose aspirin, should be avoided in CHF patients because they can cause fluid retention
D
NSAIDs should be avoided in patients with heart failure. They cause sodium and water retention, as well as an increase in systemic vascular resistance which may lead to cardiac decompensation. Patients with heart failure who take NSAIDs have a tenfold increased risk of hospitalization for exacerbation of their CHF. NSAIDs alone in patients with normal ventricular function have not been associated with initial episodes of heart failure.
NSAIDs, including high-dose aspirin (325 mg/day), may decrease or negate entirely the beneficial unloading effects of ACE inhibition. They have been shown to have a negative impact on the long-term morbidity and mortality benefits that ACE inhibitors provide. Sulindac and low-dose aspirin (81 mg/day) are less likely to cause these negative effects.
Which one of the following drugs used to treat rheumatoid arthritis can delay the progression of the disease? (check one)
A. Aspirin
B. Ibuprofen
C. Indomethacin (Indocin)
D. Capsaicin (Zostrix)
E. Hydroxychloroquine (Plaquenil)
E
Hydroxychloroquine, originally developed as an antimalarial drug, is a well-known DMARD that can slow the progression of rheumatoid arthritis. Aspirin, indomethacin, and ibuprofen are anti-inflammatory agents. They relieve pain and improve mobility, but do not alter the progression of the disease. Capsaicin, a topical substance-P depleter, can relieve pain symptoms.
Which one of the following is the most common risk factor for retinal detachment? (check one)
A. Posterior detachment of the vitreous
B. Hyphema
C. Glaucoma
D. Cataract surgery
E. Diabetic retinopathy
A
Vitreous detachment = separation of the posterior aspect of the vitreous from the retina, which exerts traction on the retina and can result in a retinal tear and detachment.
Symptoms of retinal detachment may include light flashes (photopsia), a sudden appearance or increase in “floaters” or peripheral visual field loss, any of which should prompt an ophthalmology referral.
Cataract surgery can result in premature shrinkage of the vitreous and thereby poses an increased risk, but vitreous detachment resulting from other processes is more common. Hyphema, glaucoma, and diabetic retinopathy are not specific risk factors for retinal detachment.
The mother of an 4-week-old male asks about the viral gastroenteritis vaccine. You advise that it is (check one)
A. routinely given at the 12-month visit
B. associated with an increased risk for intussusception
C. initiated at 6-12 weeks of age
D. indicated only for immunocompromised children
E. indicated only for children attending day care
C
Rotavirus vaccine (RotaTeq) vaccination is given at 2, 4, and 6 months of age; all three doses should be administered by 32 weeks of age. Unlike the vaccine RotaShield, which was marketed in 1999, RotaTeq is not known to increase the risk for intussusception.
Which one of the following is true regarding PPD testing for tuberculosis? (check one)
A. Patients who have converted within the past year should be treated, regardless of age
B. In patients who previously received a BCG vaccination, the threshold for a positive test is 25 mm of induration
C. Patients who test positive only on the second step of a two-step PPD test, given 2 weeks after the first test, are at high risk for development of active disease
D. PPD testing is contraindicated in patients who are HIV positive
A
Because the risk of developing active disease is highest in patients within 2 years after conversion, recent converters should generally be treated regardless of age.
BCG vaccination has a limited effect on PPD reactivity; tests should not be interpreted any differently in patients who have previously received BCG. The use of a two-step approach (i.e., retesting 1–4 weeks later in patients who initially test negative) is designed to decrease the false-negative rate of PPD testing. The significance of a positive result on either phase of the test is the same. Patients who are HIV positive are at higher risk for false-negative PPDs and active disease, but PPD testing is not contraindicated.
When a woman less than 50 years of age develops vulvar cancer, which one of the following associated conditions is most frequently present? (check one)
A. Human papillomavirus
B. Lichen sclerosus
C. Diabetes mellitus
D. Syphilis
E. Lymphogranuloma venereum
A
There has been an increase in vulvar cancer in women 35–65 years of age over the last decade. This increase is associated with HPV, particularly subtypes 16 and 18.
Lichen sclerosus is associated with vulvar cancer in older women.
Which one of the following is the most common cause of death for African-Americans in the United States? (check one)
A. Heart disease
B. Stroke
C. Cancer
D. Accidental injuries
E. Homicide
A
Heart disease is the leading cause of death in the U.S., and this holds true for both men and women. Among men the only ethnicity for which heart disease is not the most common cause of death is Asian/Pacific Islander.
A 78-year-old asymptomatic male is found to have a platelet count of 90,000/mm3 (N 150,000–300,000) and a slightly decreased WBC count. Which one of the following would be most consistent with a diagnosis of myelodysplastic syndrome?
A. A normal RBC count and indices
B. Normocytic anemia
C. Microcytic anemia
D. Macrocytic anemia
E. Polycythemia
D
Myelodysplastic syndrome is a hematologic malignancy with a predisposition to leukemic transformation. It can present with findings of anemia, thrombocytopenia, neutropenia, or any combination of these. Anemia occurs in 80%–85% of patients and is typically MACROcytic.
A 69-year-old male with type 2 diabetes mellitus comes to your office for a routine follow-up visit. He takes insulin glargine (Lantus) as a basal insulin, with meal-time boluses of insulin lispro (Humalog). He reports repeated episodes of hypoglycemia with blood glucose levels in the 40–50 mg/dL range. He treats them appropriately by consuming about 15 g of carbohydrates. He has a history of severe episodes of hypoglycemia requiring emergency services. In addition to insulin, his current medications include simvastatin (Zocor), lisinopril (Prinivil, Zestril), and aspirin. He has both diabetic autonomic neuropathy and retinopathy.
Which one of the following factors in this patient’s case is the most significant predictor of severe hypoglycemia?
A. His age
B. His sex
C. His medications
D. His previous episodes of severe hypoglycemia
E. His diabetic autonomic neuropathy
A 35-year-old primigravid schoolteacher awakens with a rash clinically consistent with varicella early in the 38th week of her pregnancy. She had a negative varicella titer early in her pregnancy. The clinical course is mild and all vesicles have either crusted over or healed 1 week later. She has an uncomplicated labor and vaginal delivery at 40 weeks gestation, and delivers a healthy-appearing male.
Of the following options, which one is the most appropriate initial management for the newborn?
(check one)
A. Intravenously administered varicella immune globulin
B. A weight-appropriate dose of intravenous acyclovir (Zovirax)
C. Varicella vaccine
D. Combination treatment with varicella vaccine, intravenous acyclovir, and varicella immune globulin
E. Close observation only
E
Varicella vaccination is contraindicated during pregnancy. The patient should avoid contact with infected individuals until safe postpartum immunization is possible. Maternal varicella infection is esp. problematic during weeks 13–20 of pregnancy and when the onset of maternal symptoms occurs from 5 days before until 2 days after delivery.
Varicella Ig should be given to pregnant women following a known exposure, term infants born within the 7-day window described above and preterm infants. Those who develop any signs of varicella infection also be given IV acyclovir. Term infants delivered more than 5 days after the onset of maternal varicella are thought to have adequate passive immunity for protection and the expected benign course generally requires only observation.
Which one of the following activities is most likely to be impaired in early dementia?
A. Dressing
B. Eating
C. Toileting
D. Grooming
E. Cooking
E
Basic ADLs, such as dressing, eating, toileting, and grooming, are generally intact in early dementia. In contrast, IADLs, such as managing money and medications, shopping, cooking, housekeeping, and transportation, which often require calculation or planning, are frequently impaired in early dementia.
A 70-year-old retired farmer presents with an angulated right knee and a painful hip. He asks you about the possibility of having knee replacement surgery, although he is not eager to do so. You would advise him that the major indication for knee replacement is?
A. Severe joint pain
B. Marked joint space narrowing on radiologic studies
C. Destruction and loss of motion of the contralateral joint
D. An acutely infected joint
A
The major indication for joint replacement is severe joint pain. Loss of joint function and radiographic evidence of severe destruction of the joint may also be considered in the decision. The appearance of the joint and the status of the contralateral joint may be minor considerations. Surgical insertion of a foreign body into an infected joint is contraindicated.
A 61-year-old female is found to have a serum calcium level of 11.6 mg/dL (N 8.6–10.2) on routine laboratory screening. To confirm the hypercalcemia you order an ionized calcium level, which is 1.49 mmol/L (N 1.14–1.32). Additional testing reveals an intact parathyroid hormone level of 126 pg/mL (N 15–75) and a urine calcium excretion of 386 mg/24 hr (N 100–300). Which one of the following is the most likely cause of the patient’s hypercalcemia?
A. Primary hyperparathyroidism
B. Malignancy
C. Familial hypocalciuric hypercalcemia
D. Hypoparathyroidism
E. Hyperthyroidism
A
Intact parathyroid hormone (PTH) will be suppressed in cases of malignancy-associated hypercalcemia, except for extremely rare cases of parathyroid carcinoma. Thyrotoxicosis-induced bone resorption elevates serum calcium, which also results in suppression of PTH.
Patients with familial hypocalciuric hypercalcemia (FHH) have moderate hypercalcemia but relatively low urinary calcium excretion, PTH levels can be normal or only mildly elevated despite the hypercalcemia. This mild elevation can lead to an erroneous diagnosis of primary hyperparathyroidism. The conditions can be differentiated by a 24-hour urine collection for calcium; calcium levels will be high/normal in patients with primary hyperparathyroidism and low in patients with FHH.
A 72-year-old female sees you for preoperative evaluation prior to cataract surgery. Her history and physical examination are unremarkable, and she has no medical problems other than bilateral cataracts.
Which one of the following is recommended prior to surgery in this patient? (check one)
A. An EKG only
B. An EKG and chest radiography
C. A CBC only
D. A CBC and serum electrolytes
E. No testing
E
According to a recent Cochrane review, routine preoperative testing prior to cataract surgery does not decrease intraoperative or postoperative complications. The American Heart Association recommends against routine preoperative testing in asymptomatic patients undergoing low-risk procedures, since the cardiac risk associated with such procedures is less than 1%.
Which one of the following is true regarding death certificates? (check one)
A. The immediate cause of death is the final or terminal cause of death, such as cardiac arrest
B. A physician can certify a death from a natural cause but a coroner or medical examiner must certify a death due to any other cause
C. In a case of unknown or probable cause of death, the manner of death is designated as “uncertain”
D. Death certificates are part of the patient’s medical record and, as such, are confidential and regulated by HIPAA laws
E. In a case of death due to an accidental fall, the immediate attending physician must complete the death certificate
B
An 18-year-old male comes to your office because of the recent onset of recurrent, unpredictable episodes of palpitations, sweating, dyspnea, gastrointestinal distress, dizziness, and paresthesias. His physical examination is unremarkable except for moderate obesity. Laboratory findings, including a CBC, blood chemistry profile, and thyroid-stimulating hormone (TSH) level, reveal no abnormalities.
The most likely diagnosis is: (check one)
A. mitral valve prolapse
B. paroxysmal supraventricular tachycardia
C. pheochromocytoma
D. generalized anxiety disorder
E. panic disorder
E
Panic disorder typically presents with the symptoms described, in late adolescence or early adulthood. The attacks are sporadic and last 10–60 minutes.
Generalized anxiety disorder is more common, and common symptoms include restlessness, fatigue, muscle tension, irritability, difficulty concentrating, and sleep disturbance.
Patients with mitral valve prolapse usually have an abnormal cardiac examination.
Pheochromocytoma is associated with headache and hypertension, and usually occurs in thin patients.
Paroxysmal supraventricular tachycardia is usually not associated with gastrointestinal distress or paresthesias.
In which one of the following scenarios is a physician most likely to be protected by a Good Samaritan statute? (check one)
A. Assisting flight attendants with the care of a fellow passenger who develops respiratory distress while in flight over the United States
B. Attending to an unconscious player while acting as an unpaid volunteer physician at a high-school football game
C. Attending to a bicyclist with heat exhaustion while volunteering at a first-aid station during a fund-raising ride
D. Attending to the family member of a patient who slips and falls in the waiting room at the physician’s office
E. Attending to a nurse’s aide who collapses while the physician is staffing the hospital emergency department
A
Good Samaritan laws apply to situations in which the physician does not have a preexisting duty to provide care to the patient. On an airplane, there is no preexisting duty for a physician to attend to a fellow passenger who becomes ill. In addition, a specific federal law, the Aviation Medical Assistance Act, ensures that physicians have Good Samaritan protection if they provide medical assistance while in flight over the United States.
A physician who volunteers at an event assumes a duty to care for illness or injury in the participants. Likewise, physicians have a duty to provide emergency care to a person in need within a facility where they are working, such as a medical office or an emergency department.
The scabies mite is predominantly transmitted by: (check one)
A. Bedclothes
B. Personal contact
C. Hats
D. Pets
B
A 68-year-old white male with diabetes mellitus is hospitalized after suffering a right middle cerebral artery stroke. A nurse in the intensive-care unit calls to advise you that his blood pressure is 200/110 mm Hg. You should: (check one)
A. continue monitoring the patient
B. administer labetalol (Trandate)
C. administer nicardipine (Cardene)
D. administer nitroprusside (Nitropress)
E. administer nitroglycerin
A
Current American Heart Association guidelines for blood pressure control in stroke patients advise monitoring with no additional treatment for patients with a systolic blood pressure
Which one of the following historical features is most suggestive of congestive heart failure in a 6-month-old white male presenting with tachypnea? (check one)
A. Diaphoresis with feeding
B. Fever
C. Nasal congestion
D. Noisy respiration or wheezing
E. Staccato cough
A
Symptoms of congestive heart failure in infants are often related to feedings. Only small feedings may be tolerated, and dyspnea may develop with feedings. Profuse perspiration with feedings, is characteristic, and related to adrenergic drive, as feeding is the infants greatest exertion
Fever and nasal congestion are more suggestive of infectious problems. Noisy respiration or wheezing does not distinguish between congestive heart failure, asthma, and infectious processes. A staccato cough is more suggestive of an infectious process, including pertussis.
Which one of the following is true concerning Paget’s disease of bone? (check one)
A. It is a precursor of multiple myeloma
B. Both bone formation and bone resorption are increased
C. The treatment of choice for symptomatic disease is a calcium channel blocker
D. Pagetic bone pain is difficult to relieve and resistant to medical treatment
E. Extracellular calcium homeostasis is typically abnormal
B
Paget’s disease of bone is a focal disorder of skeletal metabolism in which all elements of skeletal remodeling (resorption, formation, and mineralization) are increased.
There is no known relationship between Paget’s disease and multiple myeloma, although most cases of sarcoma in patients over 50 arise in pagetic bone. The preferred treatment for nearly all patients with symptomatic disease is one of the newer bisphosphonates.
Treatment of bone pain resulting from Paget’s disease is generally very satisfactory, and in fact, relief may continue for many months or years after treatment is stopped, lending support for intermittent symptomatic therapy.
Finally, despite the massive bone turnover, extracellular calcium homeostasis is almost always normal.
A 42-year-old male seeks your advice regarding smoking cessation. You recommend a smoking cessation class, as well as varenicline (Chantix).
You caution him that the most common side effect is: (check one)
A. dermatitis
B. diarrhea
C. edema
D. hirsutism
E. nausea
E
The most common adverse event attributed to varenicline at a dosage of 1 mg twice a day is nausea, occurring in approximately 30%–50% of patients. Taking the drug with food lessens the nausea.
A 13-year-old male presents with a 3-week history of left lower thigh and knee pain. There is no history of a specific injury, and his past medical history is negative. He has had no fevers, night sweats, or weight loss, and the pain does not awaken him at night. He tried out for the basketball team but had to quit because of the pain, which was worse when he tried to run.
Which one of the following physical examination findings would be pathognomonic for slipped capital femoral epiphysis? (check one)
A. Excessive forward passive motion of the tibia with the knee flexed
B. Lateral displacement of the patella with active knee flexion
C. Limited internal rotation of the flexed hip
D. Reduced hip abduction with the hip flexed
E. Inability to extend the hip past the neutral position
C
Slipped capital femoral epiphysis (SCFE) typically occurs in young adolescents during the growth spurt. Physical activity, obesity, and male gender are predisposing factors for the development of this condition, in which the femoral head is displaced posteriorly through the growth plate. There is pain with physical activity, most commonly in the upper thigh anteriorly, but one-third of patients present with referred lower thigh or knee pain, which can make accurate and timely diagnosis more difficult. The hallmark of SCFE on examination is limited internal rotation of the hip. Specific to SCFE is the even greater limitation of internal rotation when the hip is flexed to 90°. No other pediatric condition has this physical finding, which makes the maneuver very useful in children with lower extremity pain. Orthopedic consultation is advised if SCFE is suspected. Hip extension and abduction are also limited in SCFE, but these findings are nonspecific. The knee findings in this patient are not associated with SCFE.
A 70-year-old white female complains of two episodes of urinary incontinence. On both occasions she was unable to reach a bathroom in time to prevent loss of urine. The first episode occurred when she was in her car and the second while she was in a shopping mall. She is reluctant to go out because of this problem.
The most likely cause of her problem is: (check one)
A. overflow incontinence
B. stress incontinence
C. urge incontinence
D. functional incontinence
C
In the neurologically intact individual the most common subtypes are stress incontinence, which occurs with coughing or lifting; urge incontinence, which occurs when patients sense the urge to void but are unable to inhibit leakage long enough to reach the toilet; and overflow incontinence, which occurs when the bladder cannot empty normally and becomes overdistended.
The term functional incontinence is applied to those cases where lower urinary tract function is intact but other factors such as immobility and severe cognitive impairment lead to incontinence.
For mild urge incontinence, as in this patient, the approach to this problem should be behavioral. For more severe cases, various pharmacologic agents, including anticholinergics are useful. Failure of these modalities should lead to urodynamic testing and consideration of surgery.
An 8-year-old male is brought to your office for evaluation of recurrent headaches. His mother explains that the headaches occur at least twice a week and often require him to miss school. The patient says he sometimes feels nauseated and that being in a dark room helps. His mother states that she had migraines as a child. The child’s only other medical issue is constipation. A head CT ordered by another physician was negative.
Which one of the following would be best for preventing these episodes? (check one)
A. Sumatriptan (Imitrex)
B. Ibuprofen
C. Carbamazepine (Tegretol)
D. Propranolol (Inderal)
E. Amitriptyline
D
This patient most likely is suffering from recurrent migraine headaches; at the described frequency and intensity, he meets the criteria for prophylactic medication. Ibuprofen or acetaminophen could still be used as rescue medications, but a daily agent is indicated and propranolol is the best choice for this patient.
Sumatriptan is not approved for children under the age of 12 years. Carbamazepine has significant side effects and requires monitoring. Amitriptyline is a commonly used agent, but it could worsen his constipation.
Which one of the following is associated with the use of percutaneous endoscopic gastrostomy (PEG) tubes? (check one)
A. A reduced risk of aspiration pneumonia in patients with dysphagia
B. Increased use of restraints
C. Improved nutritional status in nursing-home residents with dementia
D. Improved quality of life for patients with dementia
B
Studies have shown that PEG tubes do not improve nutritional status or quality of life for residents with dementia, nor do they decrease the risk of aspiration pneumonia, although aspiration risk may possibly be decreased if the feeding tube is placed below the gastroduodenal junction. Feeding tubes can also cause discomfort and agitation, leading to an increased use of restraints.
A 45-year-old female with rheumatoid arthritis has a hemoglobin level of 9.5 g/dL (N 11.5-16.0). Her arthritis is well controlled with methotrexate. Further evaluation reveals the following:
Hematocrit…………29.0% (N 35.0-47.0)
Mean corpuscular volume…………78 µm3 (N 80-98)
Platelets…………230,000/mm3 (N 150,000-400,000)
WBCs…………6900/mm3 (N 4000-11,000)
Differential…………normal
Serum iron…………15 µg/dL (N 50-170)
Total iron binding capacity…………150 µg/dL (N 45-70)
Iron saturation…………10% (N 15-50)
Serum ferritin…………7 ng/mL (N 12-150)
Reticulocyte count…………8 x 109/L (N 10-100)
Stool guaiac…………negative x 3
Which one of the following would be the most appropriate next step?
A. Evaluation for a source of blood loss
B. Hemoglobin electrophoresis to screen for thalassemia
C. Stopping the methotrexate and beginning an alternative treatment for rheumatoid arthritis
D. No further evaluation
A
Anemia of chronic disease is characterized by the underproduction of red cells due to low serum iron caused by the uptake of iron by the reticuloendothelial system. Total-body iron stores are increased but the iron in storage is not available for red cell production. This anemia is normochromic and normocytic, and is associated with a reduction in iron, transferrin, and transferrin saturation. Ferritin is either normal or increased, reflecting both the increased iron within the reticuloendothelial system and increases due to immune activation (acute phase reactant).
In iron deficiency anemia, total-body iron levels are low, leading to hypochromia and microcytosis, low iron levels, increased transferrin levels, and reduced ferritin levels.
This patient’s anemia is most likely multifactorial, with anemia of chronic disease and drug effects playing a role. However, she also has iron deficiency, and searching for a source of blood loss would be important. With thalassemia, marked microcytosis is seen, and with hemolysis, slight macrocytosis and an increased reticulocyte count would be expected.
A 16-year-old female cross-country runner has pain around both ankles. On examination, pain is elicited on foot inversion and there is decreased motion of the hind foot and peroneal tightness. A rigid flat foot also is observed. Which one of the following is the most likely diagnosis?
A. Non-ossification of the os trigonum
B. Sever’s apophysitis
C. Plantar fasciitis
D. Navicular stress fracture
E. Tarsal coalition
E
Tarsal coalition is the fusion of two or more tarsal bones. Pain occurs around the ankle, and there is decreased ROM of the hindfoot and pain on foot inversion on examination.
Os trigonum results from non-ossification of cartilage. It usually is unilateral and causes palpable tenderness of the heel.
Sever’s apophysitis is inflammation of the calcaneal apophysis, and causes pain in the heel.
Plantar fasciitis causes tenderness over the anteromedial heel.
Navicular stress fractures are tender over the dorsomedial navicular
In prescribing an exercise program for elderly, community-dwelling patients, it is important to note that: (check one)
A. Graded exercise stress testing should be done before beginning the program
B. Target heart rates should be 80% of the predicted maximum
C. The initial routines can be as short as 6 minutes repeated throughout the day and still be beneficial
D. Treadmill walking is especially beneficial to patients with peripheral neuropathy
C
Initial exercise routines for the elderly can be as short as 6 minutes in duration. Even 30 minutes per week of exercise has been shown to be beneficial. Graded exercise testing need not be done, especially if low-level exercise is planned. A target heart rate of 60%–75% of the predicted maximum should be set as a ceiling. Patients with peripheral neuropathy should not perform treadmill walking or step aerobics because of the risk of damage to their feet.
Which one of the following is the most common cause of bacterial diarrhea? (check one)
A. Listeria monocytogenes
B. Escherichia coli O157:H7
C. Shigella dysenteriae
D. Campylobacter jejuni
E. Salmonella enterica
D
The treatment of acute and significant diarrhea often requires a specific diagnosis. Epidemiologic studies have shown that Campylobacter infections are the leading cause of bacterial diarrhea in the U.S.
A 25-year-old white female comes to your office complaining of abdominal pain. She requests that you hospitalize her and do whatever is necessary to get rid of the pain that has been present for a number of years. She has difficulty describing the pain. She is a single parent, and becomes defensive when asked about her previous marriage, stating only that her former husband is an alcoholic, “just like my father.” Her previous medical history includes an appendectomy, a cholecystectomy, and a hysterectomy. On physical examination she appears healthy and a CBC, erythrocyte sedimentation rate, serum amylase level, serum electrolyte levels, and multiple chemical profile are all normal. Management of this patient should include which one of the following? (check one)
A. Long-term use of antidepressants
B. Referral to a surgeon for exploratory laparotomy
C. Informing her that her problems are psychogenic and that there is nothing to worry about
D. Hospitalization as requested, then consultation with a psychiatrist
E. Scheduling frequent, regular office visits
E
Most patients with somatoform disorder are F and are of low socioeconomic status. They have high utilization of medical services, usually reflected by a thick medical chart, and are often single parents. Many of these patients seek and are ultimately granted surgical procedures, and it is not uncommon for them to have multiple procedures, especially involving the pelvic area. Often there are associated psychiatric symptoms such as anxiety, depression, suicidal threats, alcohol or drug abuse, interpersonal or occupational difficulties, and antisocial behavior. A background of a dysfunctional family unit in which one or both parents abused alcohol or drugs or were somatically preoccupied is also quite common. Unfortunately, these individuals tend to marry alcohol abusers, and thus continue the pattern of dysfunctional family life.
Treatment should be by one primary physician where an established relationship and regular visits can curtail the dramatic symptoms that many times lead to hospitalization. The family physician is in a position to monitor family dynamics and provide direction on such issues as alcoholism and child abuse. Each office visit should be accompanied by a physical examination, and the temptation to tell the patient that the problem is not physical should be avoided. Knowing the patient well helps to avoid unnecessary hospitalization, diagnostic procedures, surgery, and laboratory tests. These should be done only if clearly indicated. Psychotropic medications should be avoided except when clearly indicated, as medications reinforce the sick role, may be abused, and may be used for suicidal gestures. Following these recommendations significantly decreases the cost of care for the patient.
A rural community college has requested your guidance in offering a preventive health program to its students. The most appropriate plan would include which one of the following? (check one)
A. Mammograms for female students
B. Lead poisoning screening for all students
C. Stool occult blood kits for students
D. Smoking cessation programs
E. An annual routine physical examination for all students
D
The U.S. Preventive Services Task Force recommends:
- routine physical examination every 3–5 years for young adults until the age of 40.
- Mammograms are not recommended until age 40.
- Lead screening is recommended for at-risk individuals between 6 mo and 6 yo.
- Colorectal cancer screening for average-risk individuals is recommended at age 50.
- Counseling on tobacco/substance abuse is recommended as part of all routine preventive care.
A 14-year-old African-American female presents for a routine evaluation. On examination, you note a rubbery, well-defined, nontender breast mass approximately 2 cm in diameter. The patient denies any history of breast tenderness, nipple discharge, or skin changes. The most likely diagnosis is: (check one)
A. Fibrocystic breast disease
B. Fibroadenoma
C. Benign breast cyst
D. Cystosarcoma phyllodes
E. Intraductal papilloma
B
Fibroadenoma is the most common benign breast mass, accounting for approximately two-thirds of all adolescent breast masses. It is characterized by a slow growing, nontender, rubbery, well-defined mass, most commonly located in the UOQ. Size varies, and is most commonly in the range of 2–3 cm.
Fibrocystic disease is found in older adolescents and is characterized by bilateral nodularity and cyclic tenderness.
Benign breast cysts are characterized by a spongy, tender mass with symptoms exacerbated by menses. Cysts are frequently multiple, and spontaneous regression occurs in 50% of patients.
Cystosarcoma phyllodes is a rare tumor with malignant potential, although most are benign. It presents as a firm, rubbery mass that may enlarge rapidly. Skin necrosis is usually associated with the tumor.
Intraductal papillomas are usually benign but do have malignant potential. They are commonly subareolar and are associated with nipple discharge. These tumors are rare in the adolescent population.
Which one of the following is the preferred treatment for scabies? (check one)
A. Topical benzoyl peroxide, 10%
B. Topical crotamiton (Eurax), 10%
C. Topical permethrin (Elimite), 5%
D. Topical lindane, 1%
E. Oral ivermectin (Stromectol), 200 mg
C
Permethrin and lindane are the two most studied topical treatments for scabies, though studies have shown that permethrin to be more effective than lindane. However, the potential neurotoxicity of lindane, especially with repeated applications, has limited its use.
Other topical treatments include benzoyl benzoate and crotamiton. Crotamiton has significantly less efficacy than permethrin at 4 weeks (61% vs 89%). Several controlled trials have assessed the efficacy of a single dose of ivermectin (200 g/kg) for the treatment of scabies. In one placebo-controlled trial, 37 of 50 patients treated with ivermectin (74%) were cured.
A 25-year-old male who came to your office for a pre-employment physical examination is found to have 2+ protein on a dipstick urine test. You repeat the examination three times within the next month and results are still positive. Results of a 24-hour urine collection show protein excretion of Additional appropriate evaluation for this man’s problem at this time includes which one of the following?
A. Serum and urine protein electrophoresis
B. Antinuclear antibody
C. Serum albumin and lipid levels
D. Renal ultrasonography
E. No specific additional testing
E
Patients orthostatic proteinuria. This benign condition occurs in about 3%–5% of adolescents and young adults. It is characterized by increased protein excretion in the upright position, but normal protein excretion when the patient is supine. It is diagnosed using split urine collections as described in the question. The daytime specimen has an increased concentration of protein, while the nighttime specimen contains a normal concentration. Since this is a benign condition with normal renal function, no further evaluation is necessary.
A 60-year-old male is recovering from a non–Q-wave myocardial infarction. He has a 40-pack-year smoking history, currently smokes a pack of cigarettes per day, and has a strong family history of coronary artery disease. Studies ordered by the cardiologist showed no indication for any coronary artery procedures. His BMI is 27.5 kg/m 2 and his blood pressure is 130/70 mm Hg. Laboratory tests reveal a fasting blood glucose level of 85 mg/dL, a total cholesterol level of 195 mg/dL, and an LDL-cholesterol level of 95 mg/dL.
Which one of the following secondary prevention measures would be LEAST likely to improve this patient’s cardiovascular outcome? (check one)
A. A weight reduction diet
B. A β-blocker
C. A statin
D. An antiplatelet agent
E. Smoking cessation
A
Although dietary management may be appropriate, a weight reduction diet is not likely to improve this patient’s cardiovascular outcome. In fact, even if this person were obese, there is insufficient evidence that weight reduction would decrease his cardiovascular mortality. There is good evidence that the other options, even β-blockers in a patient with normal blood pressure, are indicated. All of these measures have evidence to support their usefulness for secondary prevention of coronary artery disease.
A 67-year-old male sees you for knee pain from osteoarthritis. It has not responded to his usual treatment, and you treat him with an intra-articular corticosteroid injection. It is mid-November, and he tells you that he has not received the influenza vaccine this year. He has also never received pneumococcal vaccine. He has a history of allergic rhinitis, treated with intranasal corticosteroids. Which one of the following is true regarding pneumococcal vaccine and influenza vaccine for this patient?
A. The immunizations should be administered at least 4 weeks apart
B. Administration of both immunizations should be delayed 4 weeks because of immunosuppression
C. Administration of influenza vaccine should be delayed for 4 weeks because it is a live attenuated vaccine
D. Administration of pneumococcal vaccine should be delayed for 4 weeks because it is contraindicated with simultaneous intra-articular corticosteroids
E. It is acceptable to administer both immunizations at this visit
E
Low-dose topical, oral, nasal, and intra-articular corticosteroids are not immunosuppressive and do not contraindicate administration of any vaccine. Influenza vaccine and pneumococcal vaccine can be given together. Neither is a live vaccine.
A 40-year-old runner complains of gradually worsening pain on the lateral aspect of his foot. He runs on asphalt, and has increased his mileage from 2 miles/day to 5 miles/day over the last 2 weeks. Palpation causes pain over the lateral 5th metatarsal. The pain is also reproduced when he jumps on the affected leg. When you ask about his shoes he tells you he bought them several years ago.
Which one of the following is the most likely diagnosis?
A. Ligamentous sprain of the arch
B. Stress fracture
C. Plantar fasciitis
D. Osteoarthritis of the metatarsal joint
B
Running injuries are primarily caused by overuse due to training errors. Runners should be instructed to increase their mileage gradually. A stress fracture causes localized tenderness and swelling in superficial bones, and the pain can be reproduced by having the patient jump on the affected leg.
Plantar fasciitis causes burning pain in the heel and there is tenderness of the plantar fascia where it inserts onto the medial tubercle of the calcaneus.
A 70-year-old male presents to your office for a follow-up visit for hypertension. He was started on lisinopril (Prinivil, Zestril), 20 mg daily, 1 month ago. Laboratory tests from his last visit, including a CBC and a complete metabolic panel, were normal except for a serum creatinine level of 1.5 mg/dL (N 0.6–1.5). A follow-up renal panel obtained yesterday shows a creatinine level of 3.2 mg/dL and a BUN of 34 mg/dL (N 8–25).
Which one of the following is the most likely cause of this patient’s increased creatinine level? (check one)
A. Bilateral renal artery stenosis
B. Coarctation of the aorta
C. Essential hypertension
D. Hyperaldosteronism
E. Pheochromocytoma
A
Classic clinical clues that suggest renal-artery stenosis include the
- onset of stage 2 HTN (blood pressure >160/100 mm Hg) after 50 yo or in the absence of a family history of HTN
- HTN associated with renal insufficiency, especially if renal function worsens after the administration of an agent that blocks the RAAS (ie lisinopril)
- HTN with repeated hospital admissions for heart failure
- drug-resistant HTN (defined as BP above the goal despite treatment with 3 drugs from different classes at optimal doses).
The other conditions mentioned do not cause a significant rise in serum creatinine after treatment with an ACE inhibitor.
In a patient with chronic hepatitis B, which one of the following findings suggests that the infection is in the active phase? (check one)
A. A normal liver biopsy
B. Detectable levels of HBeAb
C. Detectable levels of HBsAb
D. Elevated levels of ALT
E. Undetectable levels of HBV DNA
D
Chronic hepatitis B has three major phases: immune-tolerant, immune-active, and inactive-carrier.There usually is a linear transition from one phase to the next, but reactivation from immune-carrier to immune-active phase also can be seen.
Active viral replication occurs during the immune-tolerant phase when there is little or no evidence of disease activity, and this can last for many years before progressing to the immune-active phase (evidenced by elevated AST/ALT and HBeAg (indicating high levels of HBV DNA)).
Most patients with chronic hepatitis B eventually transition to the inactive-carrier phase, which is characterized by the clearance of HBeAg and the development of anti-HBeAg, accompanied by normalization of liver enzymes and greatly reduced levels of hepatitis B virus in the bloodstream.
A 50-year-old Hispanic male has a solitary 5-mm pulmonary nodule on a chest radiograph. His only medical problem is severe osteoarthritis. He quit smoking 10 years ago.
Which one of the following would be the most appropriate follow-up for the pulmonary nodule? (check one)
A. Positron emission tomography (PET)
B. Chest CT
C. A repeat chest radiograph in 6 weeks
D. A repeat chest radiograph in 6 months
B
Solitary pulmonary nodules ≥8 mm in diameter with a “ground-glass” appearance, an irregular border, and a doubling time of 1 month to 1 year suggest malignancy, but smaller lesions should also be evaluated, especially in a patient with a history of smoking.
CT is the imaging modality of choice to reevaluate pulmonary nodules seen on a xray.
PET is an appropriate next step when the cancer pretest probability and imaging results are discordant.
Patients with notable nodule growth during follow-up should undergo a biopsy.
An 18-year-old single white female at 30 weeks’ gestation presents to the hospital with uterine contractions 10 minutes apart. Her previous pregnancy 18 months ago resulted in a preterm birth at 29 weeks’ gestation. The most accurate test to determine whether this patient will need hospitalization and tocolysis would be: (check one)
A. Serum corticotropin-releasing hormone
B. Maternal serum alpha-fetoprotein
C. Serum human chorionic gonadotropin (hCG)
D. Salivary estriol concentration
E. Vaginal fetal fibronectin
E
Of the biochemical markers listed, the most clinically useful test to differentiate women who are at high risk for impending preterm delivery from those who are not is the fetal fibronectin in cervical or vaginal secretions.
In symptomatic women, this is most accurate in predicting spontaneous preterm delivery within 7–10 days. It is less accurate in those who are asymptomatic.
If the fetal fibronectin is negative, it may be possible to avoid interventions such as hospitalization, tocolysis, and corticosteroid administration.
A 70-year-old African-American male undergoes routine sigmoidoscopy. He has a long history of constipation, hypertension, and diet-controlled type 2 diabetes mellitus. The examination reveals brown to black leopard spotting of the colonic mucosa.
You would now: (check one)
A. perform a metastatic workup
B. review his medications
C. prescribe oral corticosteroids
D. prescribe antibiotics and a proton pump inhibitor
E. check his stool for Clostridium difficile
B
This patient has melanosis coli, which is a benign condition resulting from abuse of anthraquinone laxatives such as cascara, senna, or aloe. The condition resolves with discontinuation of the medication.
A 4-year-old is brought to the emergency department with abdominal pain and is noted to have 3+ proteinuria on a dipstick. Three days later the pain has resolved spontaneously, and a repeat urinalysis in your office shows 2+ proteinuria with normal findings on microscopic examination. A metabolic panel, including creatinine and total protein, is also normal.
Which one of the following would be most appropriate at this point? (check one)
A. Renal ultrasonography
B. A spot first morning urine protein/creatinine ratio
C. An antinuclear antibody and complement panel
D. Referral to a nephrologist
B
When proteinuria is noted on a dipstick and the history, examination, full urinalysis, and serum studies suggest no obvious underlying problem or renal insufficiency, a urine protein/creatinine ratio is recommended, as the test correlates well with 24-hour urine protein, which is particularly difficult to collect in a younger patient.
Renal ultrasonography is appropriate once renal insufficiency or nephritis is established.
If pathogenic proteinuria is confirmed, an antinuclear antibody and/or complement panel may be indicated.
A nephrology referral is not necessary until the presence of kidney disease or proteinuria from a cause other than benign postural proteinuria is confirmed.
A 27-year-old female radiology technician developed an area of redness over the left interscapular region while visiting a friend in Paris last week. The rash has progressed to include the area shown in Figure 10 and the patient says it itches. She recalls feeling somewhat tired and achy once she arrived in Paris but attributed this to jet lag. She denies any other systemic symptoms. Your examination reveals no significant findings except for the rash. Of the following, which one is most consistent with this patient’s history and examination? (check one)
A. Guttate psoriasis
B. Tinea versicolor
C. Radiation dermatitis
D. Cutaneous T-cell lymphoma
E. Pityriasis rosea
E
This presentation is typical of pityriasis rosea - mild prodrome (thought to be jet lag by this patient) followed by the development of an ovoid salmon-colored, slightly raised herald patch (commonly on the trunk), followed by an outbreak of smaller, similar lesions that trend along Langer’s lines.
In this case, clear evidence of the herald patch remains visible in the left interscapular region, which is helpful in confirming the diagnosis.
Guttate psoriasis shares some features with pityriasis rosea in that it can appear suddenly and often follows a triggering incident such as a streptococcal infection, which could be confused with a prodromal phase; however, the absence of a herald patch and the smaller but thicker erythematous lesions differentiate psoriasis from pityriasis rosea. Tinea versicolor often involves the upper trunk and may appear as a lightly erythematous, scaling rash, but the onset is more gradual than in this case. Although this patient may be exposed to low levels of radiation in her job, radiation dermatitis requires doses such as those administered in cancer treatment protocols and would generally be limited to the field of exposure. Cutaneous T-cell lymphoma usually presents as a nonspecific dermatitis, most commonly in men over the age of 50.
An infectious etiology for pityriasis rosea is strongly suspected, although none has been identified. There is some evidence that the agent may be human herpesvirus 6. The illness generally resolves within 2 months, leaving no residual signs other than postinflammatory hyperpigmentation.
A 72-year-old male is brought by ambulance to the ED with weakness and numbness of his left side that began earlier this morning. While in the ED he becomes comatose with infrequent, gasping breaths and is quickly intubated and placed on a ventilator. A full evaluation shows an acute ischemic right-sided stroke. His wife states that she wishes to have the ventilator stopped, as she believes this would be consistent with her husband’s wishes in this circumstance. She understands that this would precipitate the patient’s death. The wife presents a legally valid advance directive confirming her as the patient’s healthcare proxy. Which one of the following responses to the wife’s request is most ethically appropriate?
A. Withdraw the ventilator as requested
B. Contact the hospital ethics committee to initiate the legal requirements to process the wife’s request
C. Inform the wife that all life-sustaining care should be given until the patient’s condition has been determined to be irreversible
D. Inform the wife that intubation may have been avoided in the emergency department, but once life-sustaining care has been initiated it should not be withdrawn
E. Promptly contact hospital security or the local law enforcement agency to report the wife’s request
A
The patient has instituted a legal advance directive and his proxy’s request should be respected as his own and the care withdrawn. If there were no advance directive the decision in this case would become more difficult, and might require a family conference or the involvement of an ethics committee.
A patient’s condition does not need to be terminal or irreversible to allow the removal of life-sustaining therapy. Legal involvement is rarely required in situations where advance directives are already available and valid.
Pallidotomy is a surgical therapy for: (check one)
A. Alzheimer’s disease
B. Parkinson’s disease
C. Huntington’s chorea
D. Vascular dementia
E. Temporal lobe epilepsy
B
Thalamotomy (partial removal of thalamus) and pallidotomy (destruction of the globus pallidus), contralateral to the side of the body that is most affected, are most effective for the treatment of disabling unilateral tremor and dyskinesia from Parkinson’s disease.
A 14-year-old male has open and closed comedones without evidence of surrounding inflammation on his face and upper back. Which one of the following is the most appropriate initial treatment?
A. Topical antibiotics
B. Topical retinoids
C. Oral antibiotics
D. Oral isotretinoin
B
Comedones are noninflammatory acne lesions. Inflammatory lesions include papules, pustules, and nodules. Grading acne based on the type of lesion and severity helps guide therapy.
Topical retinoids prevent the formation of comedones and reduce their number, and are indicated as monotherapy for noninflammatory acne.
Topical antibiotics are used primarily for the treatment of mild to moderate inflammatory or mixed acne.
Oral antibiotics are effective for the treatment of moderate to severe acne.
Oral isotretinoin is reserved for treatment of severe, recalcitrant acne.
Which one of the following statements is true about celiac disease (gluten-sensitive enteropathy) in adults? (check one)
A. It is more common among African-Americans
B. Symptoms are limited to gastrointestinal complaints
C. Type 2 diabetics are at increased risk for the disease
D. Serum antibody tests are sensitive and specific
E. Colonoscopy with mucosal biopsy is required to make the diagnosis
D
Serum antibody testing, especially IgA antiendomysial antibody, is highly sensitive and specific and readily available at a cost of about $100 to $200. Definitive diagnosis generally requires EGD with a biopsy of the distal duodenum to detect characteristic villous flattening
A 28-year-old male recreational runner has a midshaft posteromedial tibial stress fracture. Although he can walk without pain, he cannot run without pain. The most appropriate treatment at this point includes which one of the following? (check one)
A. A short leg walking cast
B. A non–weight-bearing short leg cast
C. A non–weight-bearing long leg cast
D. An air stirrup leg brace (Aircast)
E. Low-intensity ultrasonic pulse therapy
D
Midshaft posteromedial tibial stress fractures are common and are considered low risk. Management consists of relative rest from running and avoiding other activities that cause pain. Once usual daily activities are pain free, low-impact exercise can be initiated and followed by a gradual return to previous levels of running. A pneumatic stirrup leg brace has been found to be helpful during treatment.
Non–weight bearing is not necessary, as this patient can walk without pain. Casting is not recommended. Ultrasonic pulse therapy has helped fracture healing in some instances, but has not been shown to be beneficial in stress fractures.
A 48-year-old white female complains of anxiety and difficulty concentrating at home and at work. She reports that the symptoms have increased over the last 2 months because of her daughter’s marital difficulties. She has had similar symptoms along with intermittent depression since she was a teenager. She admits to a loss of pleasure in work and recreational activities. Which one of the following is LEAST likely to help her coexistent depressive symptoms? (check one)
A. Buspirone (BuSpar)
B. Nortriptyline (Aventyl)
C. Escitalopram (Lexapro)
D. Venlafaxine (Effexor)
E. Paroxetine (Paxil)
A
Buspirone is indicated for the treatment of anxiety - It is not an established antidepressant. Its advantages include the absence of addictive potential and sedation; like antidepressants, the onset of benefit is often delayed for several weeks.
Which one of the following is a physiologic difference between males and females that can affect the pharmacokinetics of medications with a narrow therapeutic index?
A. A consistently higher glomerular filtration rate in women
B. The typically higher BMI in women
C. Smaller fat stores in women
D. Greater gastric acid secretion in women
E. Slower gastrointestinal transit times in women
E
GI transit times are slower in women than in men, which can diminish the absorption of medications such as metoprolol, theophylline, and verapamil. In addition, women should wait longer after eating before taking medications that should be administered on an empty stomach, such as ampicillin, captopril, levothyroxine, loratadine, and tetracycline.
Women also secrete less gastric acid than men, so they may need to drink an acidic beverage to aid in absorption of medications that require an acidic environment, such as ketoconazole.
Women usually have lower BMIs than men, and may need smaller loading or bolus dosages of medications to avoid unnecessary adverse reactions.
Women typically have higher fat stores than men, so lipophilic drugs such as benzodiazepines and neuromuscular blockers have a longer duration of action.
Women also have lower GFR than men, resulting in slower clearance of medications that are eliminated renally, such as digoxin and methotrexate.
Which one of the following should be avoided when treating pain in the elderly? (check one)
A. Fentanyl (Sublimaze)
B. Hydrocodone
C. Meperidine (Demerol)
D. Morphine
E. Oxycodone (OxyContin)
C
meperidine should not be used in the elderly because its metabolite can accumulate and cause seizures
A 54-year-old male presents to the emergency department with an acute onset of chest pain. His cardiac risk factors include hypertension, hyperlipidemia, and a positive family history. His temperature is 37.0°C (98.6°F), pulse rate 80 beats/min, blood pressure 155/86 mm Hg, and respiratory rate 22/min. His oxygen saturation is 95% on room air. An EKG shows rare unifocal PVCs and nonspecific ST-T–wave changes. Initial cardiac markers are negative.
Which one of the following would be most appropriate at this point?
A. Helical (spiral) CT of the chest
B. Echocardiography
C. PA and lateral chest films
D. A ventilation-perfusion scan
E. Magnetic resonance angiography
C
PA and lateral CXR are still valuable in the early evaluation of patients with chest pain. While they do not confirm or rule out the presence of myocardial ischemia, other causes of chest pain may be evident, such as pneumothorax, pneumonia, or heart failure. The CXR may also provide clues about other possible diagnoses, such as pulmonary embolism, aortic disease, or neoplasia.
The other tests listed often have a role in the evaluation of chest pain, but none has supplanted the plain chest film as the best initial imaging study.
According to the U.S. Preventive Services Task Force, multivitamin supplements in the geriatric age group: (check one)
A. are not recommended for prevention of any disorder
B. should be prescribed to reduce elevated homocysteine levels
C. decrease coronary atherosclerosis
D. decrease the incidence of lung cancer
E. decrease the incidence of colon cancer
A
The U.S. Preventive Services Task Force makes no specific recommendations for vitamins or antioxidants to prevent cancer or cardiovascular disease. Moreover, it makes no specific recommendations for vitamin supplements for any condition.
A 30-year-old white male complains of several weeks of nasal stuffiness, purulent nasal discharge, and facial pain. He does not respond to a 3-day course of trimethoprim/sulfamethoxazole (Bactrim, Septra). Follow-up treatment with 2 weeks of amoxicillin/clavulanate (Augmentin) is similarly ineffective. Of the following diagnostic options, which one is most appropriate at this time? (check one)
A. Pulmonary function testing
B. Coronal CT of the sinuses
C. Culture and sensitivity testing of the discharge
D. Erythrocyte sedimentation rate
B
This patient has a clinical presentation consistent with acute sinusitis. Failure to respond to adequate antibiotic therapy suggests either a complication, progression to chronic sinusitis, or a different, confounding diagnosis. The diagnostic procedure of choice in this situation is coronal CT of the sinuses, due to its increased sensitivity and competitive cost when compared with standard radiographs.
Cultures of the nasal discharge give unreliable results because of bacterial contamination from the resident flora of the nose. The other options listed do not contribute to the diagnosis and treatment of sinusitis.
A 38-year-old white female presents to your office with a 4-cm palpable nodule in her right breast. Fine-needle aspiration yields 4 cc of bloody fluid. Following the aspiration, the breast nodule is no longer palpable. Which one of the following would be most appropriate at this point? (check one)
A. No further workup
B. Cytologic examination of the fluid
C. Surgical referral for core needle biopsy
D. Surgical referral for excisional biopsy
E. Ultrasonography of the breast
B
When straw-colored or grey-green fluid is obtained by FNA of a breast nodule and the lesion completely disappears, the diagnosis is simple cyst. The fluid should not be sent for analysis because the risk for cancer is exceedingly small.
If the fluid is bloody or otherwise unusual, it should be sent for cytologic examination because about 7% of bloodstained aspirates are associated with cancer
The sensitivity of a test is defined as: (check one)
A. the probability of disease before a test is performed
B. the probability of disease after a test is performed
C. the percentage of patients with a positive test result who are confirmed to have the disease
D. the percentage of patients with the disease who have a positive test result
E. the percentage of patients without the disease who have a negative test result
D
Sensitivity is the percentage of patients with a disease who have a positive test result.
Specificity is the percentage of patients without the disease who have a negative test result.
Pretest probability is the probability of disease before a test is performed.
Posttest probability is the probability of disease after a test is performed.
Positive predictive value is the percentage of patients with a positive test result who are confirmed to have the disease.
On his first screening colonoscopy, a 67-year-old male is found to have a 0.5-cm adenomatous polyp with low-grade dysplasia. According to current guidelines, when should this patient have his next colonoscopy?
A. 6 months
B. 1 year
C. 3 years
D. 5 years
E. Screening is no longer necessary
D
patients with one or two small (
A 20-year-old patient comes to the emergency department complaining of shortness of breath. On examination his heart rate is 180 beats/min, and his blood pressure is 122/68 mm Hg. An EKG reveals a narrow complex tachycardia with a regular rhythm.
Which one of the following would be the most appropriate initial treatment? (check one)
A. Amiodarone (Cordarone)
B. Diltiazem (Cardizem)
C. Adenosine (Adenocard)
D. Magnesium
E. Synchronized cardioversion
A
After vagal maneuvers are attempted in a stable patient with supraventricular tachycardia, the patient should be given a 6-mg dose of adenosine by rapid IV push. If conversion does not occur, a 12-mg dose should be given. This dose may be repeated once. If the patient is unstable, immediate synchronized cardioversion should be administered.
svtAc = stabilize ventricular tachycardias w/ Adenosine then Cardioversion
In which one of the following patients can a diagnosis of osteoporosis be made?
A. A 58-year-old female who fractured her wrist when she slipped and fell on her outstretched hand onto a carpeted floor
B. A 62-year-old female who sustained a pelvic fracture in a motor vehicle accident
C. A 52-year-old female with a T-score of +2.5 on bone mineral density testing of her hip
D. A 67-year-old female with a T-score of –1.7 on BMD testing of her spine
E. A 72-year-old female with a T-score of –2.0 on BMD testing of her spine
A
Osteoporosis is defined as a fragility or low-impact fracture, or as a spine or hip bone mineral density > 2.5 SD below the mean for young, healthy women.
A fracture of the radius caused by a fall from a standing position would be considered a low-impact fracture.
A fracture resulting from a motor vehicle accident would be considered a high-impact fracture, which is not diagnostic for 11 osteoporosis.
A T-score of –2.5 or less is considered osteoporosis, a T-score between –1.0 and –2.5 is considered osteopenia, and a T-score of –1.0 or higher is considered normal.
A 34-year-old female presents to the emergency department with a severe migraine headache unresponsive to tramadol (Ultram) and sumatriptan (Imitrex) at home. She takes fluoxetine (Prozac) for depression. Soon after being given an injection of meperidine (Demerol), she develops agitation, diaphoresis, tremor, diarrhea, fever, and incoordination. The most likely cause of this patient’s symptoms is: (check one)
A. Serotonin syndrome
B. Thyrotoxic storm
C. Sepsis
D. Viral encephalitis
E. Panic attack
A
Combination of an SSRI with a drug that increases serotonin concentrations may induce the potentially life-threatening serotonin syndrome, with mental status changes, agitation, myoclonus, hyperreflexia, diaphoresis, shivering, tremor, diarrhea, incoordination, and fever. These drugs include MAOi, tramadol, sibutramine, meperidine, sumatriptan, lithium, St. John’s wort, ginkgo biloba, and atypical antipsychotic agents.
A 21-year-old primigravida at 10 weeks gestation has a negative titer for rubella. The best procedure to follow is to?
A. Institute a (-globulin regimen and maintain it throughout her pregnancy
B. Administer rubella vaccine after 12 weeks gestation
C. Administer rubella vaccine immediately post partum
D. Administer rubella vaccine 12 weeks post partum
C
Rubella has been directly responsible for inestimable pregnancy wastage, as well as for severe congenital malformations.
Identification and vaccination of unimmunized women immediately after childbirth or abortion is recommended. The vaccine should be avoided shortly before or during pregnancy since it is an attenuated live virus
The use of globulin to prevent viremia in nonimmune subjects exposed to rubella is not recommended. Because of herd immunity there is a very low likelihood that this patient will be exposed to rubella.
The mother of an 8-year-old female is concerned about purple “warts” on her daughter’s hands. The mother explains that the lesions started a few months ago on the right hand along the top of most of the knuckles and interphalangeal joints, and she has recently noticed them on the left hand. The child has no other complaints and the mother denies any unusual behaviors. A physical examination is unremarkable except for the slightly violaceous, flat-topped lesions the mother described.
What is the most likely cause for this patient’s finger lesions? (check one)
A. Dermatomyositis
B. Aggressive warts
C. Rubbing/wringing of the hands
D. Bulimia nervosa
E. Child abuse
A
One of the most characteristic findings in dermatomyositis is Gottron’s papules, which are flat-topped, sometimes violaceous papules that often occur on most, if not all, of the knuckles and interphalangeal joints.
A 36-year-old male presents with pain over the lumbar paraspinal muscles. He says the pain began suddenly while he was shoveling snow. Which one of the following is true regarding this patients injury? (check one)
A. Systemic corticosteroids speed recovery
B. Exercises specific to low back injuries speed recovery
C. Opioids have significant advantages for symptom relief when compared with NSAIDs or acetaminophen
D. Continued activity rather than bed rest helps speed recovery
E. Trigger-point injections are superior to placebo in relieving acute back pain
D
Studies have demonstrated that bed rest is detrimental to recovery from low back pain. Patients should be encouraged to remain as active as possible.
Exercises designed specifically for the treatment of low back pain have not been shown to be helpful. Neither opioids nor trigger-point injections have shown superiority over placebo, NSAIDs, or acetaminophen in relieving acute back pain. There is no good evidence to suggest that systemic corticosteroids are effective for low back pain with or without sciatica.
A 24-year-old female has a history of mood swings over the past several months, which have created marital and financial problems, in addition to jeopardizing her career as a television news reporter. You have made a diagnosis of bipolar disorder, and she has finally accepted the need for treatment. However, she insists that you choose a drug that “won’t make me fat.”
Which one of the following would be best for addressing her concerns? (check one)
A. Aripiprazole (Abilify)
B. Olanzapine (Zyprexa)
C. Quetiapine (Seroquel)
D. Risperidone (Risperdal)
A
All of the atypical antipsychotics are associated with some degree of weight gain. Of the choices listed, aripiprazole is associated with the least amount of weight gain, generally less than 1 kilogram.
The other agents listed are likely to cause considerably more weight gain.
For which one of the following respiratory infections should antibiotic therapy be initiated immediately upon diagnosis? (check one)
A. Bronchitis
B. Epiglottitis
C. Laryngitis
D. Rhinosinusitis
E. Tracheitis
B
Many infections of the respiratory tract have a viral etiology, and when this is the case early antibiotic treatment offers little to no benefit. Once the clinical course of a respiratory illness exceeds the expected length for a viral illness, it may be proper to initiate antibiotic treatment for a suspected atypical or secondary bacterial infection.
Epiglottitis is one exception to this approach because of the possibility of a bacterial infection, particularly with Haemophilus influenzae type b, that can produce a rapidly worsening, potentially fatal airway compromise. When epiglottitis is suspected based on findings such as hoarseness, dysphagia, stridor, drooling, fever, chills, and respiratory distress, IV antibiotic treatment should be instituted immediately, ideally with a ß-lactam drug that exhibits activity against methicillin-resistant Staphylococcus aureus.
A 15-year-old white female who has had regular periods since age 12 comes to your office because of secondary amenorrhea and a milky discharge from her breasts. A pregnancy test is negative.
The best test for initial evaluation of the pituitary in this patient is:
A. plasma antidiuretic hormone
B. plasma ACTH
C. serum prolactin
D. serum FSH and LH
E. fasting growth hormone
C
The most common secretory pituitary adenomas are prolactinomas. They cause galactorrhea and hypogonadism, including amenorrhea, infertility, and impotence.
Growth hormone–secreting tumors, which are the next most common secretory pituitary tumors, cause acromegaly or gigantism.
Next in frequency are corticotropic (ACTH-secreting) adenomas, which cause cortisol excess (Cushing’s disease).
Glycoprotein hormone-secreting pituitary adenomas (secreting TSH, LH, or FSH) are the least common. TSH-secreting adenomas are a rare cause of hyperthyroidism. Paradoxically, most patients with gonadotropin-secreting adenomas have hypogonadism.
You are considering how useful a new treatment might be in preventing stroke. A well designed study is reported with 200 patients in the treated group and 200 patients in the untreated group. The study finds a 5-year risk of stroke of 3% in the treated group versus 5% in the untreated group. Assuming this study is valid and applicable to your patient population, how many patients would you have to treat for 5 years to prevent one stroke (number needed to treat, or NNT)? (check one)
A. 400
B. 200
C. 100
D. 50
E. 25
D
The relative risk reduction (RRR) is the proportional decrease in disease incidence in the treated group relative to the incidence in the control group. In this example the 3% incidence in the treated group is 40% less than the 5% incidence in the control group: (5%–3%)/5% = 40%. The absolute risk reduction (ARR) is the difference between the incidence of disease in the treatment group and the incidence in the control group. In this example the ARR is 5% minus 3% = 2%. The number needed to treat (NNT) equals the reciprocal of the ARR: 1/.02 = 50. The RRR is not a very useful statistic in clinical practice. It amplifies small differences and makes clinically insignificant findings appear significant because it essentially ignores the baseline risk of the outcome event. The ARR provides a more useful measure of clinical effect. It answers the question “How much will I decrease my patient’s risk of an adverse outcome by this treatment?” The NNT is also very useful for clinicians, as it answers the question, “How many patients will I need to treat to prevent one adverse outcome?”
Which one of the following is the best radiographic test for confirming the diagnosis of renal colic? (check one)
A. A KUB radiograph
B. Ultrasonography
C. CT
D. Intravenous pyelography
E. MRI
C
CT is the gold standard for the diagnosis of renal colic. Its sensitivity and specificity are superior to those of ultrasonography and intravenous pyelography. Noncalcium stones may be missed by plain radiography but visualized by CT. MRI is a poor tool for visualizing stones.
Increasing patient copayments for prescription medications results in: (check one)
A. an increase in the number of prescriptions filled by low-income medical-assistance recipients
B. little demonstrable change in purchasing patterns
C. increased hospitalizations for patients with chronic illnesses
D. improved efficiency in the utilization of outpatient medical services
C
Increasing prescription copayments results in a decrease in the number of prescriptions filled and worsening clinical outcomes for patients with heart failure, diabetes mellitus, hyperlipidemia, and schizophrenia. With each 10% increase in copayments, it is estimated that overall prescription spending decreases 2%–6%. The cited study found that up to 25% of Medicaid recipients, faced with a copayment, could not afford to fill at least one prescription in the previous year.
You are a member of a committee at your local hospital that has been asked to develop measures to reduce the incidence of postoperative methicillin-resistant Staphylococcus aureus(MRSA) infections. Which one of the following would be most effective for preventing these infections? (check one)
A. Give preoperative antibiotics to all surgical patients to eradicate bacteria
B. Screen all admitted patients for MRSA and use antibiotics pre- and postoperatively in positive cases
C. Culture the nares of all hospital employees upon hiring and on a routine basis thereafter
D. Institute an intensive program of good hand washing for all employees
D
A 4-year-old white male is brought to your office because he has had a low-grade fever and decreased oral intake over the past few days. On examination you note shallow oral ulcerations confined to the posterior pharynx. Which one of the following is the most likely diagnosis? (check one)
A. Herpangina
B. Herpes
C. Mononucleosis
D. Roseola infantum
E. Rubella
A
Herpangina is a febrile disease caused by coxsackieviruses and echoviruses. Vesicles and subsequent ulcers develop in the posterior pharyngeal area.
Herpes infection causes a gingivostomatitis that involves the anterior mouth.
Mononucleosis may be associated with petechiae of the soft palate, but does not usually cause pharyngeal lesions.
The exanthem in roseola usually coincides with defervescence. Mucosal involvement is not noted.
Rubella may cause an enanthem of pinpoint petechiae involving the soft palate (Forschheimer spots), but not the pharynx.
A 50-year-old male is brought to the emergency department because of a syncopal episode.Prior to the episode, he felt bad for 30 minutes, then developed nausea followed by vomiting. During a second bout of vomiting he blacked out and fell to the floor. His wife did not observe any seizure activity, and he was unconscious only for a few seconds. His history is otherwise negative, his past medical history is unremarkable, and he currently takes no medications. A physical examination is normal.
Which one of the following would be the most helpful next step?
A. CT of the head
B. Carotid ultrasonography
C. A CBC and complete metabolic profile
D. Echocardiography
E. An EKG
E
Syncope work-up begins with a H/P to identify those at risk for a poor outcome. Patients who have a prodrome of have a cardiac arrhythmia. Patients with longer prodromes with N/V are likely to have vasovagal syncope, which is a benign process. Patients who pass out after standing for 2 minutes are likely to have orthostatic hypotension.
In most cases, the recommended test is an EKG. If the EKG is normal, dysrhythmias are not a likely cause of the syncopal episode. Laboratory testing and advanced studies such as CT or echocardiography are not necessary unless there are specific findings in either the history or the physical examination.
A 50-year-old female presents with a 3-week history of a moderately pruritic rash, characterized by flat-topped violaceous papules 3–4 mm in size. The lesions are located primarily on the volar wrists and forearms, lower legs, and dorsa of both feet. Ten days after the rash first appeared she went to the emergency department and was treated for “possible scabies,” but the treatment has made little or no difference.
Which one of the following treatments is indicated at this time? (check one)
A. Clobetasol (Cormax, Temovate) 0.05% ointment
B. Permethrin 5% cream
C. Dipyridamole (Persantine)
D. Triamcinolone 0.1% cream
A
This patient has lichen planus - pruritic, symmetrically distributed violaceous flat-topped papules, usually 3–6 mm in size. First-line treatment is with high-potency topical corticosteroids /clobetasol, as mid-potency topical agents such as triamcinolone are ineffective.
Topical calcineurin inhibitors, including tacrolimus, can be used in cases not responding to topical corticosteroids.
While scabies can masquerade as a variety of other dermatoses, retreatment with a scabicide is not indicated in this patient.
The 1990 Patient Self-Determination Act requires that: (check one)
A. the process for advance directives be standardized for all 50 states
B. a living will be implemented for patients upon admission to the hospital
C. hospitals ask patients about advance directives
D. verbally expressed wishes be honored for individuals who do not have a written advance directive
C
The 1990 Patient Self-Determination Act (PSDA) requires hospitals, nursing homes, and health care programs to ask patients about advance directives and then incorporate the information into medical records
A 67-year-old white male with hypertension and chronic kidney disease presents with the recent onset of excessive thirst, frequent urination, and blurred vision. Laboratory testing reveals a fasting blood glucose level of 270 mg/dL, a hemoglobin A 1c of 8.5%, a BUN level of 32 mg/dL, and a serum creatinine level of 2.3 mg/dL. His calculated glomerular filtration rate is 28 mL/min.
Which one of the following medications should you start at this time? (check one)
A. Glipizide (Glucotrol)
B. Metformin (Glucophage)
C. Glyburide (DiaBeta)
D. Acarbose (Precose)
A
Glipizide does not have an active metabolite, and is safe in patients with chronic renal disease.
Metformin should be avoided in patients with a Cr >1.5 mg/dL for men or >1.4 mg/dL for women.
Glyburide has an active metabolite that is eliminated renally. This metabolite can accumulate in patients with chronic kidney disease, resulting in prolonged hypoglycemia.
Acarbose should be avoided in patients with chronic kidney disease, as it has not been evaluated in these patients.
In the elderly, the risk of heat wave–related death is highest in those who: (check one)
A. have COPD
B. have diabetes and are insulin dependent
C. have a functioning fan, but not air conditioning
D. are homebound
D
Factors associated with a higher risk of heat-related death include being confined to bed, not leaving home daily, and being unable to care for oneself. Among medical conditions, the highest risk is associated with preexisting psychiatric illnesses, followed by cardiovascular disease, use of psychotropic medications, and pulmonary disease.
A 70-year-old male complains of lower-extremity pain. Increased pain with which one of the following would be most consistent with lumbar spinal stenosis? (check one)
A. Lumbar spine extension
B. Lumbar spine flexion
C. Internal hip rotation
D. Pressure against the lateral hip and trochanter
E. Walking uphill
A
Lumbar spine extension increases lumbar lordosis, which decreases the cross-sectional area of the spinal canal, thereby compressing the spinal cord further. Walking downhill can cause this.
Spinal flexion that decreases lordosis has the opposite effect, and will usually improve the pain, as will sitting.
Pain with internal hip rotation is characteristic of hip arthritis and is often felt in the groin.
Pain in the lateral hip is more typical of trochanteric bursitis.
Increased pain walking uphill is more typical of vascular claudication.
A 5-year-old female is seen for a kindergarten physical and is noted to be below the 3rd percentile for height. A review of her chart shows that her height curve has progressively fallen further below the 3rd percentile over the past year. She was previously at the 50th percentile for height. The physical examination is otherwise normal, but your workup shows that her bone age is delayed.Of the following conditions, which one is the most likely cause of her short stature? (check one)
A. Constitutional growth delay
B. Growth hormone deficiency
C. Genetic short stature
D. Turner syndrome
E. Skeletal dysplasia
B
This patient has delayed bone age + reduced growth velocity, which suggests an underlying systemic cause, such as growth hormone deficiency
Although bone age can be delayed with constitutional growth delay, after 24 months of age, growth curves are parallel to the 3rd percentile.
Bone age would be normal with genetic short stature, Turner syndrome, skeletal dysplasia; but the latter two have dysmorphic features
A mother brings her 2-month-old infant to the emergency department because of profuse vomiting and severe diarrhea. The infant is dehydrated, has a cardiac arrhythmia, appears to have ambiguous genitalia, and is in distress.
This presentation suggests a diagnosis of: (check one)
A. acute gastroenteritis
B. hypertrophic pyloric stenosis
C. congenital adrenal hyperplasia
D. congenital intestinal malrotation
E. Turner’s syndrome
C
Congenital adrenal hyperplasia - caused by an inherited deficiency of any of the enzymes necessary for the biosynthesis of cortisol. In patients with the salt-losing CAH variant, symptoms begin shortly after birth with
- failure to regain birth weight
- progressive weight loss secondary to dehydration and vomiting
- anorexia
- Disturbances in cardiac rate and rhythm may occur due to electrolyte imbalances
- cyanosis and dyspnea
- in genetic males, various degrees of hypospadias may be seen, with or without a bifid scrotum or cryptorchidism.
An otherwise healthy 40-year-old male comes to your office for follow-up of elevated liver enzymes on an insurance examination. He is 173 cm (68 in) tall and weighs 113 kg (250 lb) (BMI 37.7 kg/m2). He says he drinks about two beers per week. Findings are normal on a physical examination, except for a slightly enlarged liver. AST and ALT levels are twice the upper limits of normal.
Which one of the following would be the most appropriate next step?
A. A liver biopsy
B. Ultrasonography of the liver
C. Colonoscopy
D. Testing for viral hepatitis
E. Repeat AST and ALT levels in 3 months
D
Nonalcoholic fatty liver disease is the most likely diagnosis in this patient, but hepatitis B and C should be ruled out. The patient’s alcohol consumption of less than two drinks per week makes alcoholic fatty liver disease unlikely. A liver biopsy would not be appropriate at this time. Liver ultrasonography should be considered after hepatitis B and C are ruled out. The patient is younger than the recommended screening age for colonoscopy.
A 2-year-old Hispanic male with a 3-day history of nasal congestion presents with a barking cough and hoarseness. He is afebrile. The examination reveals tachypnea, inspiratory and expiratory stridor, noticeable intercostal retractions, and good color.
Which one of the following is indicated?
A. Albuterol syrup and the use of a humidifier
B. Inhaled albuterol (Proventil, Ventolin)
C. Aerosolized epinephrine and intramuscular dexamethasone
D. Visualization of the epiglottis, and ceftriaxone (Rocephin)
C
viral laryngotracheobronchitis (croup) - cough, respiratory stridor, and distress result from edema of the subglottic portion of the upper airway.
Stridor + intercostal retractions are indications for aerosolized epinephrine + intramuscular dexamethasone, and hospitalization may be required for observation and continued treatment.
Antibiotics do not have a role in the treatment of viral croup, and attempted visualization of the epiglottis is not indicated since it will increase the child’s anxiety and worsen the symptoms.
Which one of the following is an effective screening method for ovarian cancer in elderly females at average risk? (check one)
A. Annual CA-125 assays
B. Annual pelvic ultrasonography
C. Annual Papanicolaou (Pap) tests and pelvic examinations
D. No currently available method
D
A 30-year-old female asks you whether she should have a colonoscopy, as her father was diagnosed with colon cancer at the age of 58. There are no other family members with a history of colon polyps or cancer.
You recommend that she have her first screening colonoscopy: (check one)
A. now and every 5 years if normal
B. now and every 10 years if normal
C. at age 40 and then every 5 years if normal
D. at age 40 and then every 10 years if normal
E. at age 50 and then every 5 years if normal
C
Patients who have one first degree relative diagnosed with colorectal cancer or adenomatous polyps before age 60, or at least two second degree relatives with colorectal cancer, are in the highest risk group. They should start colon cancer screening at age 40, or 10 years before the earliest age at which an affected relative was diagnosed (whichever comes first) and be rescreened every 5 years.
A 36-year-old white male complains of episodic pain in the rectum over the past several years. The pain occurs every 3–6 weeks and is sharp, cramp-like, and severe. It lasts from 1 to 15 minutes. He has no other gastrointestinal complaints. A physical examination, including a digital rectal examination and anoscopy, is normal.
The most likely diagnosis is:
A. fecal impaction
B. coccygodynia
C. anal fissure
D. proctalgia fugax
E. sacral nerve neuralgia
D
proctalgia fugax - episodic, sudden, sharp pains in the anorectal area lasting several seconds to minutes. The diagnosis is based on a history that fits the classic picture in a patient with a normal examination
Which one of the following is consistent with spinal stenosis but not with a herniated vertebral disk? (check one)
A. Numbness
B. Muscle weakness
C. Pain relieved by sitting
D. Pain relieved by standing
C
Causes of low back pain include vertebral disk herniation and spinal stenosis. Numbness and muscle weakness may be present in both.
Pain from spinal stenosis is relieved by sitting and aggravated by standing, whereas the opposite is true for pain from a herniated disk.
A middle-aged hairdresser presents with a complaint of soreness of the proximal nail folds of several fingers on either hand, which has slowly worsened over the last 6 months. The nails appear thickened and distorted. Otherwise she is healthy and has no evidence of systemic disease. Which one of the following would be the most effective initial treatment? (check one)
A. Soaking in a dilute iodine solution twice daily to cleanse and sterilize the nail beds
B. Oral amoxicillin/clavulanate (Augmentin) for up to 4-6 weeks
C. Topical betamethasone dipropionate (Diprolene) applied twice daily to the nail folds for 3-4 weeks
D. Evaluation for HIV, hepatitis C, psoriasis, and rheumatoid arthritis
C
Chronic paronychia is a common condition in workers whose hands are exposed to chemical irritants or are wet for long periods of time. This patient is an otherwise healthy hairdresser, with frequent exposure to irritants. The patient should be advised to avoid exposure to harsh chemicals and water. In addition, the use of strong topical corticosteroids over several weeks can greatly reduce the inflammation, allowing the nail folds to return to normal and helping the cuticles recover their natural barrier to infection.
Soaking in iodine solution would kill bacteria, but would also perpetuate the chronic irritation. Because the condition is related to chemical and water irritation, a prolonged course of antibiotics should not be the first treatment step, and could have serious side effects. There is no need to explore less likely autoimmune causes for nail changes at this time.
A 70-year-old male without underlying lung disease presents with a 36-hour history of fever, body aches, cough, and dyspnea. He did not receive influenza vaccine this year, and was recently exposed to his grandson who had influenza.
On examination the patient has a temperature of 38.8°C (101.8°F), a blood pressure of 90/50 mm Hg, a heart rate of 110 beats/min, and an O2 saturation of 87% on room air. A nasal swab rapid antigen test is negative, and his WBC count is 15,000/mm3 (N 4300–10,800). A viral culture is sent to the laboratory. A chest radiograph shows a large lobar pneumonia.
You hospitalize the patient and initiate? (check one)
A. ceftriaxone (Rocephin) and azithromycin (Zithromax)
B. levofloxacin (Levaquin)
C. oseltamivir (Tamiflu)
D. oseltamivir, ceftriaxone, and azithromycin
E. oseltamivir, ceftriaxone, azithromycin, and vancomycin (Vancocin)
E
This patient has pneumonia, sepsis, and suspected coinfection with influenza. Although the rapid antigen-based nasal swab was negative, false-negative rates may be as high as 70% and this test should not be relied upon to rule out influenza. Treatment should include both antiviral and antibacterial agents that include coverage against MRSA, the most common bacterial pathogen isolated from critically ill patients with coinfection. Oseltamivir, ceftriaxone, azithromycin, and vancomycin should be initiated empirically for the pneumonia and sepsis. The criteria for sepsis are satisfied by a temperature >38.3°C, a WBC count >12,000/mm3, a respiratory rate >20/min, and a source of probable infection.
A 17-year-old female sees you for a preparticipation evaluation. She has run 5 miles a day for the last 6 months, and has lost 6 lb over the past 2 months. Her last menstrual period was 3 months ago. Other than the fact that she appears to be slightly underweight, her examination is normal.
To fit the criteria for the female athlete triad, she must have which one of the following? (check one)
A. A formal diagnosis of an eating disorder
B. Amenorrhea for 1 year
C. A Z-score on bone-density testing of –2.5 or less
D. Withdrawal bleeding after progesterone administration
E. A history of a stress fracture resulting from minimal trauma
E
female athlete triad: amenorrhea, osteoporosis, decreased energy availability (dietary restrictions and substantial energy expenditures disrupt pituitary and ovarian function)
Athletes who have amenorrhea for 6 months, disordered eating, and/or a history of a stress fracture resulting from minimal trauma should have a bone density test. Low bone mineral density for age is the term used to describe at-risk female athletes with a Z-score of –1 to –2.
- Osteoporosis is defined as having clinical risk factors for experiencing a fracture, along with a Z-score
Compared to anesthesia using only parenteral opioids, the use of epidural anesthesia in labor and delivery increases the rate of which one of the following? (check one)
A. Cesarean section
B. Low Apgar scores ( C. Maternal low backache 3 months post delivery
D. Prolonged second stage of labor
D
Effects of epidural anesthesia
- an increased duration of the second stage of labor
- an increased rate of instrument-assisted vaginal deliveries
- an increased likelihood of maternal fever
Overall, there is no statistically significant difference in the duration of the first stage of labor, the incidence of low Apgar scores, or the incidence of maternal backache at 3 months or 12 months.
Three members of the same family present with a high fever and cough that began abruptly yesterday. All three report having fevers over 40° C (104° F), painful coughs, moderate sore throats, and prostration. They have loss of appetite, but no vomiting or diarrhea. Two other family members have similar symptoms. On examination the patients appear ill and flushed. There is no cervical adenopathy, no visible pharyngeal inflammation, and no significant findings on examination of the chest. Which one of the following is the most likely diagnosis? (check one)
A. Mycoplasma pneumonia
B. Influenza-like illness
C. Bacterial bronchitis
D. Upper respiratory infection
B
Influenza - very abrupt onset, and a fever with a nonproductive cough. Patients tend to say they have never been so ill.
Mycoplasma pneumonia can spread among family members, but it is milder and has a more indolent onset and a longer incubation period.
Bacterial bronchitis is an overdiagnosed, supposed complication of URI, and is not contagious.
While the phrase cold and flu is often used, URI are not so febrile or prostrating, and coryza is the dominant syndrome sooner or later.
Legionella can have point-source epidemics, but the incubation period is longer, symptoms vary from mild illness to life-threatening pneumonia, and diarrhea is prominent in many cases.
Which one of the following should be avoided in the treatment and prophylaxis of migraine during early pregnancy? (check one)
A. Calcium channel blockers
B. Beta-blockers
C. Triptans
D. NSAIDS
C
Most medications used for prophylaxis/abortive treatment of migraines in the nonpregnant patient can also be used in pregnant patients. Most ß-blockers and calcium channel blockers are safe. Acetaminophen and narcotics can be used for acute pain. Ibuprofen/NSAIDs can also be used but should be avoided late in pregnancy because it is associated with premature closure of the ductus arteriosus and oligohydramnios.
Ergotamines (Migergot) are avoided as they are uterotonic and have abortifacient properties. They have also been associated with case reports of fetal birth defects
Triptans have the potential to cause vasoconstriction of the placental and uterine vessels and should be used only if the benefit clearly outweighs the harm.
A 45-year-old white male develops disabling tremulousness, loss of voice, and a marked sense of forceful and rapid heartbeat whenever he must speak to a large group. Which one of the following drugs is likely to be of most value in enabling him to give presentations at sales and stockholders’ meetings? (check one)
A. Desipramine (Norpramin)
B. Propranolol (Inderal)
C. Alprazolam (Xanax)
D. Amantadine (Symmetrel)
E. Buspirone (BuSpar)
B
Specific phobias respond moderately well to β-blockers used prior to a performance. Since the symptoms are due to catecholamine excess, these drugs block peripheral anxiety symptoms such as tachycardia and tremulousness that can escalate subjective anxiety and impair performance.
An 11-year-old male is brought to your office for evaluation of bilateral posterior heel pain that has occurred for the past few months. He plays basketball and soccer several times a week and the pain begins several minutes into each of these activities. There is no pain at rest or with walking. The patient has not noticed any numbness, tingling, or weakness.
On examination you find no swelling or tenderness of the heel or Achilles tendon. Reflexes, strength, and range of motion at the ankle are intact, but he does have bilateral posterior heel pain when you passively dorsiflex the ankles. Which one of the following is the most likely diagnosis?
A. Achilles tendinopathy
B. Calcaneal apophysitis
C. Plantar fasciitis
D. Heel pad syndrome
E. Tarsal tunnel syndrome
B
Calcaneal apophysitis, also known as Sever disease, is the most common cause of heel pain in children, usually occurring between 5 and 11 years of age. It is thought that in these children the bones grow faster than the muscles and tendons. A tight Achilles tendon then pulls on its insertion site at the posterior calcaneus with repetitive running or jumping activities, causing microtrauma to the area. There may be swelling and tenderness in this area and passive dorsiflexion may increase the pain. Radiography is usually normal and therefore does not often aid in the diagnosis, but it may reveal a fragmented or sclerotic
calcaneal apophysis.Treatment involves decreasing pain-inducing activities, anti-inflammatory or analgesic medication if needed, ice, stretching and strengthening of the gastrocnemius-soleus complex, and the use of orthotic devices.
Plantar fasciitis and heel pad syndrome cause pain on the plantar surface of the heel rather than posteriorly.
Achilles tendinopathy causes tenderness to palpation of the Achilles tendon. Tarsal tunnel syndrome related to compression of the posterior tibial nerve causes neuropathic pain and numbness in the posteromedial ankle and heel.
A 44-year-old male sees you for evaluation of an episode of pink-tinged urine last week. He denies any flank or abdominal pain, as well as frequency, urgency, and dysuria. He has no prior history of renal or other urologic disease, and no other significant medical problems. He has a 24-pack-year smoking history. A urinalysis today reveals 8–10 RBCs/hpf. You refer him to a urologist for cystoscopy.
Which one of the following would be the most appropriate additional evaluation?
A. KUB radiography
B. Transabdominal ultrasonography
C. Voiding cystourethrography
D. CT urography
E. Magnetic resonance urography
D
CT urography or intravenous pyelography is recommended by the American College of Radiology as the most appropriate imaging procedure for hematuria in all patients, with the exception of those with generalized renal parenchymal disease, young women with hemorrhagic cystitis, children, and pregnant females.
A 60-year-old African-American male is found to have type 2 diabetes mellitus. Which one of the following should be ordered before initiating treatment with metformin (Glucophage)?
A. Serum electrolytes
B. A serum creatinine level
C. A CBC
D. A lipid panel
E. A thyroid panel
B
Metformin is contraindicated in patients with renal dysfunction, because it is associated with an increased incidene of lactic acidosis
A 58-year-old healthy white female sees you for a routine visit. She is monogamous with her husband, is a nonsmoker, has two alcoholic drinks a week, and has mild GERD. Her BMI is normal. She takes an over-the-counter H2-blocker and a multivitamin with calcium. She had a normal mammogram 1 month ago and a negative colonoscopy at age 53. She has never had a DXA scan or screening for ovarian cancer. Her family history is noncontributory.
According to the U.S. Preventive Services Task Force, you should recommend
(check one)
A. HIV screening
B. CA-125 testing for ovarian cancer screening
C. DXA for osteoporosis screening
D. colonoscopy for colorectal cancer screening
A
USPSTF and the CDC recommend that all adults age 65 years and under be screened for HIV regardless of risk factors.
The USPSTF does not recommend routine screening for ovarian cancer with a bimanual examination, transvaginal ultrasonography, or CA-125 testing.
The USPSTF recommends that women age 65 and older be screened for osteoporosis with a DXA scan. Women younger than age 65 should be screened only if their risk of fracture is equal to or greater than a 65-year-old white female with no additional risk factors.
The USPSTF recommends that women age 50–75 be screened for colorectal cancer with colonoscopy every 10 years OR with flexible sigmoidoscopy every 5 years plus fecal occult blood testing (FOBT) every 3 years OR with FOBT annually.
A 40-year-old female is scheduled for a cholecystectomy and you wish to estimate her risk for postoperative bleeding. Which one of the following provides the most sensitive method for identifying her risk? (check one)
A. Bleeding time
B. Prothrombin time (PT)
C. Activated partial thromboplastin time (aPTT)
D. Bleeding history
D
Bleeding time, activated partial thromboplastin time (aPTT), and prothrombin time (PT) are relatively poor predictors of bleeding risk. Studies have shown that baseline coagulation assays do not predict postoperative bleeding in patients undergoing general or vascular surgery who have no history that suggests a bleeding disorder. Obtaining a history for evidence of prior bleeding problems is the most sensitive and accurate method of determining a patient’s risk
A 50-year-old female reports a 1-month history of pain in her wrists. She does not recall any injury. On examination both wrists are warm but not red, feel boggy on palpation, and lack 30° of both flexion and extension. No other joints are affected. She feels fatigued and unwell, but attributes this to her busy schedule. Radiographs of the wrists are normal. Laboratory findings are unremarkable except for a mildly elevated erythrocyte sedimentation rate and a negative rheumatoid factor.
Which one of the following is the most likely diagnosis?
A. Rheumatoid arthritis
B. Osteoarthritis
C. Inapparent injury
D. Fibromyalgia
E. Lyme disease
A
Rheumatoid arthritis is most often symmetric at presentation and particularly affects the wrists and other extremity joints that have a high ratio of synovium to articular cartilage. Rheumatoid factor is often negative in the early months of the disease, although it may be positive later. Radiographs and laboratory tests are helpful, but the diagnosis is primarily clinical.
Osteoarthritis of the wrists usually involves the carpal-metacarpal joint of the thumb primarily, and the joint would be red if there were an injury.
Fibromyalgia usually involves the soft tissue of the trunk, and there is no evidence of inflammation.
Lyme disease can cause a variety of joint diseases, but not chronic symmetric arthritis.
Which one of the following medications is most appropriate for treating moderate to severe shortness of breath in a hospice patient with lung cancer? (check one)
A. Dexamethasone
B. Haloperidol
C. Scopolamine
D. Morphine
D
Morphine effectively decreases the feeling of SOB in hospice patients. Randomized, controlled trials have shown significant improvements in symptoms without a significant change in oxygen saturation.
Haloperidol can be used for nausea/vomiting and delirium, but is not helpful in the treatment of shortness of breath.
Scopolamine is used to decrease the production of secretions but is not helpful for treating dyspnea.
Corticosteroids will not manage the sensation of shortness of breath in a dying patient.
A 19-year-old college freshman consults you at the request of her cross-country coach because she has not had a period in 2 of the last 3 months. She notes that her current training regimen is much more intense than in high school last year. She has an appropriate body image and denies caloric restriction. A pregnancy test at the student health center was negative. On examination she is lean and highly trained. Her examination is otherwise normal. Which one of the following would be the most appropriate recommendation for this patient?
A. Estrogen supplementation
B. Cyclic oral contraceptive pills
C. Increased caloric intake
D. Bisphosphonate therapy
E. Discontinuation of elite-level athletics
C
This patient has exercise-related oligomenorrhea, but does not have the eating disorder that characterizes the female athlete triad. Menstrual problems in athletes do correlate with bone density loss and impaired recovery from exercise.
The main issue in well-nourished female athletes seems to be that energy intake is not increased to match energy expenditures at high levels of training. Unlike those with the female athlete triad, there is little evidence that athletes without eating disorders suffer substantial harm from exercise-induced menstrual problems.
Hormonal manipulation has not been shown to affect bone density, though it may produce withdrawal bleeding. Bisphosphonate therapy has been shown to be ineffective, and is not recommended in women of child-bearing age.
A 36-year-old male complains of clear rhinorrhea, nasal congestion, and watery, itchy eyes for several months. Tests in the past have suggested that he has an allergy to dust mites.
Which one of the following is most likely to provide the most relief from his symptoms? (check one)
A. Oral antihistamines
B. An oral leukotriene-receptor antagonist
C. Intranasal antihistamines
D. Intranasal corticosteroids
E. Furnace filters and mite-proof bedding covers
D
This patient has classic symptoms of allergic rhinitis. Intranasal corticosteroids are considered the mainstay of treatment for mild to moderate cases. In multiple studies, intranasal corticosteroid sprays have proven to be more efficacious than the other options listed, even for ocular symptoms. Air filtration systems and bedding covers have not been shown to reduce symptoms.
A 42-yo female is troubled by her lack of interest in sex. She is generally healthy, takes no medications, and has regular menstrual periods. She is content with the emotional intimacy of her marriage and has had satisfying sexual interactions in the past. She does not have any religious or cultural barriers regarding her sexuality, and asks for ideas on how to improve her situation.
Which one of the following has consistent evidence of benefit in cases such as this? (check one)
A. Cognitive-behavioral therapy
B. Viewing pornography
C. Oral estrogen
D. Oral sildenafil (Viagra)
E. Topical testosterone
E
This patient has hypoactive sexual desire disorder (HSDD); the diagnosis includes 2 components: (1) recurrent deficiency/absence of sexual desire or receptivity to sexual activity, and (2) distress about such a deficiency.
In menstruating women, oral estrogen and oral sildenafil have not been shown to be superior to placebo. CBT has been shown to be helpful for other sexual dysfunctions, but not with HSDD. Topical testosterone, in either patch or gel form, has shown consistent improvements in arousal, desire, fantasy, orgasm, and overall satisfaction in cases of HSDD.
A 45-year-old female presents to an urgent care center complaining of left-sided chest pain for the past 2 days. The pain is nonradiating and sharp in character, and increases with deep inspiration. She has no associated shortness of breath, cough, nausea, diaphoresis, or dizziness. She has no significant past medical history or recent travel history.
On examination she is afebrile, with a pulse rate of 102 beats/min, a blood pressure of 116/72 mm Hg, and a respiratory rate of 22/min. Her lungs are clear and her heartbeat is regular with no murmurs. Her lower extremities have no edema, tenderness, or varicosities.
Which one of the following is the most appropriate next step in her evaluation? (check one)
A. A high-sensitivity D-dimer test
B. A troponin I level
C. An antinuclear antibody level
D. Ultrasound examination of the veins of the lower extremities
E. Multidetector helical CT of the chest
A
This patient has a low pretest probability of PE based on the Wells criteria. She would be a good candidate for a high-sensitivity D-dimer test, with a negative test indicating a low probability of venous thromboembolism.
In patients with a low pretest probability of venous thromboembolism, ultrasonography or helical CT would not be the recommended initial evaluation. Neither troponin I nor an ANA level would be part of the recommended initial evaluation.
72-year-old white female is scheduled to undergo a total knee replacement for symptomatic osteoarthritis. She is otherwise healthy, with no history of vascular disease or DVT. She takes no routine medications. Which one of the following is most appropriate for prophylaxis against deep vein thrombosis? (check one)
A. No prophylaxis if there are no surgical complications
B. Aspirin, 325 mg daily
C. Unfractionated heparin, 5000 U subcutaneously every 12 hours
D. Thigh-high compression stockings
E. Enoxaparin (Lovenox), 30 mg subcutaneously every 12 hours
E
Prophylaxis is indicated with total knee or hip replacements. The two regimens recommended are LMWH and adjusted-dose warfarin. These may be augmented by intermittent pneumatic compression.
A 3-year-old female is brought to your office for evaluation of mild intoeing. The child’s patellae face forward, and her feet point slightly inward. Which one of the following would be most appropriate? (check one)
A. Reassurance
B. Foot stretching exercises
C. Use of orthotics
D. Use of night splints
E. Surgery
A
Intoeing, as described, is usually caused by internal tibial torsion. This problem is believed to be caused by sleeping in the prone position, and sitting on the feet. In 90% of cases, internal tibial torsion gradually resolves without intervention by the age of 8. Avoiding prone sleeping enhances resolution of the problem. Night splints, orthotics, and shoe wedges are ineffective. Surgery (osteotomy) has been associated with a high complication rate, and is therefore not recommended in mild cases before the age of 8.
A 74-year-old African-American female has moderately severe pain due to osteoarthritis. However, she is also on medication for a seizure disorder. When choosing medications to manage her chronic pain, which one of the following should be used with caution because of her history of seizures? (check one)
A. Salsalate (Disalcid)
B. Celecoxib (Celebrex)
C. Hydrocodone (Lortab)
D. Oxycodone (OxyContin)
E. Tramadol (Ultram)
E
According to the American Geriatrics Society 2002 guidelines for management of persistent pain in older persons, tramadol has efficacy and safety similar to those of equianalgesic doses of codeine and hydrocodone. However, because of the threat of seizures (rare but potential), tramadol should be used with caution in patients with a history of seizure disorder or those taking other medications that lower seizure thresholds.
A 40-year-old female comes to your office for a routine examination. She has been in good health and has no complaints other than obesity. Her mother is diabetic and the patient has had a child that weighed 9 lb at birth. Her examination is negative except for her obesity. A fasting glucose level is 128 mg/dL, and when repeated 2 days later it is 135 mg/dL. Which one of the following would be most appropriate at this point? (check one)
A. Diagnose type 2 diabetes mellitus and begin diet and exercise therapy
B. Begin an oral hypoglycemic agent
C. Order a glucose tolerance test
D. Tell the patient that she has impaired glucose homeostasis but is not diabetic
A
The criteria for diagnosing diabetes mellitus include any one of the following:
- symptoms of diabetes (polyuria, polydipsia, weight loss) PLUS one of the following
- random glucose level ≥200 mg/dL
- fasting plasma glucose level ≥126 mg/dL
- a 2-hour postprandial glucose level ≥200 mg/dL after a 75 g glucose load.
In the absence of unequivocal hyperglycemia the test must be repeated on a different day.
The criteria for impaired glucose homeostasis include either
- a fasting glucose level of 100-125 mg/dL (impaired fasting glucose) or
- a 2-hour glucose level of 140-199 mg/dL on an oral glucose tolerance test.
Normal values are now considered
A 3 yo M is brought in for evaluation of 5 days of knee pain and fever up to 101.6°F. There was no known trauma preceding these symptoms. The pain and fever respond well to oral acetaminophen but continue to recur 4 hours after each dose.
On examination the child appears well and is afebrile. He had a dose of acetaminophen about 2 hours ago. There are no signs of URI. Examination of the knee reveals no redness, warmth, or swelling, and you see no other skin changes. He has full range of motion of both the knee and hip without pain. You note tenderness to firm palpation of the proximal tibia. He is able to bear weight and walk but refuses to jump due to anticipation of pain in his knee. Plain films of the knee are normal.
The next step in the evaluation of this patient should include which one of the following?
A. Close monitoring at home
B. A CBC, a C-reactive protein level, and an erythrocyte sedimentation rate
C. Ultrasonography of the hip
D. Knee joint aspiration
E. MRI of the knee
B
Joint pain in the presence of fever with no apparent source indicates a possible infection, malignancy, or rheumatologic condition and requires further workup. CBC, CRP, and ESR can help assess for these conditions, even though none of the tests is sufficiently sensitive to rule out these diseases, and they are not specific to a single disease entity.
Knee joint aspiration would be indicated to rule out septic arthritis in the presence of a joint effusion.
If the hip were painful or had decreased ROM, then US could help identify a hip joint effusion, which would need to be aspirated.
MRI may be needed in this patient, but it would likely require sedation and thus is more invasive. Starting with laboratory work is a good first step toward identifying the source of his pain and fever.
A 52-year-old mechanic complains of an irrigation in his right eye lasting for 2 days. On direct visualization you see a small, dark foreign body on the periphery of the cornea and are able to remove it with no complications. However, there is a patch of reddish-brown discoloration extending several millimeters around the area where the foreign body had been.
Which one of the following is most appropriate for this patient? (check one)
A. Watchful waiting
B. Irrigation with 0.9% saline solution under pressure
C. An antibiotic ointment to be used every 2–4 hours
D. Gentle debridement with a #11-blade scalpel
E. Prompt ophthalmologic evaluation
E
If a metal foreign body is present on the cornea for more than 24 hours a rust ring will often be present in the superficial layer of the cornea. This material is toxic to the cornea and should be removed as soon as possible, but it is not an emergency. The proper removal of a rust ring requires the use of a slit lamp and specialized ophthalmic equipment. Referral to an eye specialist within 24–48 hours is the best management in this case.
A 28-year-old female sees you with a complaint of irregular menses. She has not had a menstrual period for 6 months. She is also concerned about weight gain, worsening acne, and dark hair on her upper lip, chin, and periareolar region. She is also interested in becoming pregnant soon. The patient tells you she has started an exercise program, which has helped with weight loss, but she continues to have amenorrhea. She has a negative urine β-hCG test, a mild elevation in free testosterone levels, and glucose intolerance.
Which one of the following would you consider initially for inducing ovulation? (check one)
A. Insulin
B. Metformin (Glucophage)
C. Ethinyl estradiol/norgestimate (Ortho Tri-Cyclen)
D. Glipizide (Glucotrol)
E. Spironolactone (Aldactone)
B
First-line agents for ovulation induction and treatment of infertility in patients with polycystic ovary syndrome (PCOS) include metformin and clomiphene, alone or in combination, and rosiglitazone
Which one of the following is the most common secondary cause of nephrotic syndrome in adults? (check one)
A. Diabetes mellitus
B. Systemic lupus erythematosus
C. Hepatitis
D. NSAIDs
E. Multiple myeloma
A
Most cases of nephrotic syndrome are caused by primary kidney disease, the most common secondary cause of nephrotic syndrome in adults is diabetes mellitus.
Other secondary causes include systemic lupus erythematosus, hepatitis B, hepatitis C, NSAIDs, amyloidosis, multiple myeloma, HIV, and preeclampsia. Primary causes include membranous nephropathy and focal segmental glomerulosclerosis, each accounting for approximately one third of cases.
A 3-year-old male is carried into the office by his mother. Yesterday evening he began complaining of pain around his right hip. Today he has a temperature of 37.6°C (99.7°F), cries when bearing weight on his right leg, and will not allow the leg to be moved in any direction. A radiograph of the hip is normal. Which one of the following would be most appropriate at this time?
A. A CBC and an erythrocyte sedimentation rate
B. A serum antinuclear antibody level
C. Ultrasonography of the hip
D. MRI of the hip
E. In-office aspiration of the hip
A
This presentation is typical of either transient synovitis or septic arthritis of the hip. Because the conditions have very different treatment regimens and outcomes, it is important to differentiate the two. It is recommended that after plain films, the first studies to be performed should be a CBC and an erythrocyte sedimentation rate (ESR).
Septic arthritis is considered highly likely in a child who has a fever over 38.7°C (101.7°F), refuses to bear weight on the leg, has a WBC >12,000 cells/mm , and ESR >40 mm/hr. If several or all of these conditions exist, aspiration 3 of the hip guided by US or fluoroscopy should be performed by an experienced practitioner. MRI may be helpful in cases that are unclear based on standard data, or if other etiologies need to be excluded.
Which one of the following is recommended for routine prenatal care? (check one)
A. Hepatitis C antibody testing
B. Parvovirus antibody testing
C. Cystic fibrosis carrier testing
D. HIV screening
E. Examination of a vaginal smear for clue cells
D
HIV screening is recommended as part of routine prenatal care, even in low-risk pregnancies. Counseling about cystic fibrosis carrier testing is recommended, but not routine testing. Hepatitis C and parvovirus antibodies are not part of routine prenatal screening. Routine screening for bacterial vaginosis with a vaginal smear for clue cells is not recommended.
A 53-year-old female is concerned about a skin lesion that has recently been changing in size and shape. On examination she is found to have a 7-mm, asymmetric, darkly pigmented lesion with some color variegation and irregular borders.
Which one of the following skin biopsy techniques is most appropriate for confirming the diagnosis? (check one)
A. A shave biopsy
B. Electrodesiccation and curettage
C. Elliiptical excision
D. Mohs surgery
C
The preferred method of biopsy for any lesion suspicious for melanoma is complete elliptical excision with a small margin of normal-appearing skin. Mohs surgery is sometimes used to treat melanomas, but is not used for the initial diagnosis.
The depth of the lesion is crucial to staging and prognosis, so shave biopsies are inadequate. A punch biopsy of the most suspicious-appearing area is appropriate if the location or size of the lesion makes full excision inappropriate or impractical, but a single punch biopsy is unlikely to capture the entire malignant portion in larger lesions. Electrodesiccation and curettage is not an appropriate treatment for melanoma.
Which one of the following decreases pain from infiltration of local anesthetics? (check one)
A. Cooling the anesthetic solution
B. Using a 22-gauge needle rather than a 30-gauge needle
C. Infiltrating quickly
D. Infiltrating through surrounding intact skin
E. Adding sodium bicarbonate to the mixture
E
The pain from infiltration of local anesthetics can be decreased by using a warm solution, using small needles, and performing the infiltration slowly. It is also helpful to add sodium bicarbonate to neutralize the anesthetic since they are shipped at an acidic pH to prolong shelf life.
An exception to this tip is bupivicaine (Marciane, Sensorcaine) as it will precipitate in the presence of sodium bicarbonate. It also helps to inject the agent through the edges of the wound (assuming the wound is not contaminated) and to pretreat the wound with topical anesthetics.
The most common presenting symptom of obstructive sleep apnea is: (check one)
A. excessive daytime sleepiness
B. snoring
C. morning headache
D. gastroesophageal reflux
E. enuresis
A
The most common presenting symptom of obstructive sleep apnea is excessive daytime sleepiness (SOR A). Other symptoms include snoring, unrefreshing or restless sleep, witnessed apneas and nocturnal choking, morning headache, nocturia or enuresis, gastroesophageal reflux, and reduced libido
A 66-year-old male has hypertension that has become difficult to manage after several years of good control on a stable medical regimen. On evaluation, his BUN level is 40 mg/dL (N 8–25) and his serum creatinine level is 2.1 mg/dL (N 0.6–1.5).
Which one of the following tests would be best to evaluate this patient for renovascular hypertension? (check one)
A. Duplex Doppler ultrasonography
B. CT angiography
C. Aortography
D. Captopril (Capoten) renography
A
Duplex Doppler US is the preferred initial test for renovascular hypertension in patients with impaired renal function.
Tests involving intravenous radiographic contrast material may cause deterioration in renal function. Captopril renography is not reliable in the setting of poor renal function. Magnetic resonance angiography also could be considered, but the association between the use of gadolinium contrast agents and nephrogenic systemic fibrosis in patients with renal dysfunction would be a concern.
Which one of the following is true about end-of-life care? (check one)
A. Physicians underestimate life expectancies
B. Most physicians are comfortable with their level of education in palliative care and pain control
C. Most patients who qualify for hospice care receive services early in the course of their illness
D. Most terminal patients want their lives prolonged as much as possible
E. Most terminal patients express a desire for a sense of control
E
Patients at the end of life have five main areas of concern: control of pain and other symptoms; avoiding a prolongation of the dying process; having a sense of control; relieving burdens on family and loved ones; and strengthening relationships with family and friends.
The definition of post-term pregnancy is a pregnancy that has reached: (check one)
A. 40 weeks’ gestation
B. 41 weeks’ gestation
C. 42 weeks’ gestation
D. 43 weeks’ gestation
C
Postdate and post-term pregnancy are terms that are used interchangeably. The postdate pregnancy is defined as a pregnancy that has reached 42 weeks of amenorrhea. This is important because perinatal mortality doubles at 42 weeks gestational age. The diagnosis of postdate pregnancy depends heavily on accurate dating methods.
In which one of the following populations does the U.S. Preventive Services Task Force support ultrasound screening for abdominal aortic aneurysm?
A. All men age 55–75
B. Males age 55–75 who currently smoke
C. Patients of both sexes age 55–75 who currently smoke
D. Men age 65–75 who have ever smoked
E. No population group
D
USPSTF recommends one-time screening for AAA by US in men age 65–75 who have ever smoked (Grade B recommendation). The USPSTF recommends against routine screening for AAA in women (Grade D recommendation).
Which one of the following confirmed findings in a 3-year-old female is diagnostic of sexual abuse? (check one)
A. Bacterial vaginosis
B. Genital herpes
C. Gonorrhea
D. Anogenital warts
E. Hepatitis
C
The diagnosis of any STI in a postnatal prepubescent child should raise immediate suspicion of sexual abuse and prompt a thorough physical evaluation, detailed historical inquiry, and testing for other common STI.
Gonorrhea, Chlamydia, Syphilis, HIV are virtually diagnostic of sexual abuse, although it is possible for perinatal transmission of Chlamydia to result in infection that can go unnoticed for as long as 2–3 years.
Genital herpes, genital warts, hepatitis B should raise a strong suspicion of possible inappropriate contact. Genital warts or herpes may result from autoinoculation, and most cases of hepatitis B appear to be contracted from nonsexual household contact.
Bacterial vaginosis provides only inconclusive evidence for sexual contact, and is the only one of the options listed for which reporting is neither required nor strongly recommended.
A 3-year-old female is brought to your office for a health maintenance examination, and her father expresses concern about her vision. Her visual acuity is 20/20 bilaterally on a tumbling E visual acuity chart. With both eyes uncovered during a cover/uncover test, the corneal light reflex in the right eye is medial to the pupil when focused on a fixed point, but the light reflex in the left eye is almost centered in the pupil. When the left eye is covered, the right eye moves quickly inward to focus on the fixed point, and the corneal light reflex is centered in the pupil. When the left eye is uncovered, the right eye returns to its original position. When you cover the right eye, no left eye movement is noted. Which one of the following is the most likely diagnosis? (check one)
A. Strabismus
B. Amblyopia
C. Cataract
D. Esotropia
E. Heterophoria
A
Strabismus is an ocular misalignment that can be diagnosed on a cover/uncover test when the corneal light reflex is deviated from its normal position slightly nasal to mid-pupil. The misaligned eye then moves to fixate on a held object when the opposite eye is covered. The eye drifts back to its original position when the opposite eye is uncovered.
Amblyopia is cortical visual impairment from abnormal eye development-most often as a result of strabismus.
Cataract is a less frequent cause of amblyopia.
Esotropia is a type of strabismus with an inward or nasal deviation of the eye that would be evidenced by a corneal light reflex lateral to its normal position. (The outward eye deviation seen in this patient is exotropia.)
Heterophoria, or latent strabismus, does not cause eye deviation when both eyes are uncovered.
In early February, you receive a call from your office nurse. Her 5-month-old daughter has been ill for several days. What started as a mild upper respiratory infection has progressed and she now has profuse rhinorrhea, a temperature of 100.2° F (37.9° C), and audible wheezing. In spite of an almost nonstop cough, she does not appear acutely ill. The organism responsible for this child’s illness is most likely to be: (check one)
A. Group B Streptococcus
B. Mycoplasma pneumoniae
C. Bordetella pertussis
D. Parainfluenza virus 3
E. Respiratory syncytial virus
E
The most common cause of pneumonia in children age 4 mo - 4 yrs is RSV. Other viruses may cause pneumonia as well. The peak incidence of respiratory syncytial virus is between 2 and 7 months of age. Wheezing and profuse rhinorrhea are characteristic and the disease typically occurs in mid-winter or early spring epidemics.
Parainfluenza 3 typically affects older infants and is not common in winter.
Mycoplasma tends to affect older children and children with bacterial illnesses; those infected with this organism generally appear more acutely ill.
When an interpreter is needed for a patient with limited English proficiency, which one of the following should be AVOIDED when possible? (check one)
A. Using mostly short sentences, with frequent pauses
B. Using diagrams and pictures
C. Addressing the patient in the second person (i.e., “you”)
D. Maintaining eye contact with the patient when speaking
E. Using an educated adult family member who is bilingual
E
A 55-year-old hospitalized white male with a history of rheumatic aortic and mitral valve disease has a 3-day history of fever, back pain, and myalgias. No definite focus of infection is found on your initial examination. His WBC count is 24,000/mm3(N 4300–10,800) with 40% polymorphonuclear leukocytes and 40% band forms. The following day, two blood cultures have grown gram-positive cocci in clusters.
Until the specific organism sensitivity is known, the most appropriate antibiotic treatment would be: (check one)
A. ciprofloxacin (Cipro)
B. nafcillin
C. streptomycin and penicillin
D. ceftriaxone (Rocephin)
E. vancomycin and gentamicin
E
This patient has endocarditis caused by a gram-positive coccus. Until sensitivities of the organism are known, treatment should include IV antibiotic coverage for Enterococcus, Streptococcus, MSSA and MRSA.
A patient who does not have a prosthetic valve should be started on vancomycin and gentamicin, with monitoring of serum levels.
Enterococcus and MRSA are often resistant to cephalosporins. If the organism proves to be Staphylococcus sensitive to nafcillin, the patient can be switched to a regimen of nafcillin and gentamicin.
An 83-year-old female is admitted to the hospital with an exacerbation of her COPD. On the second hospital day she is clinically improved but is quite disoriented, experiencing visual hallucinations, agitation, and problems with recent memory and attention span. She is noted by the nursing staff to periodically fall asleep during conversation. Her previous medical history is notable for emphysema and hypertension, but there is no history of psychiatric problems. Her blood pressure is 140/82 mm Hg, pulse 88 beats/min, and oxygen saturation 98% on 2 L of nasal O2. Which one of the following does this patient most likely have? (check one)
A. Dementia
B. Acute depression
C. Mania
D. Delirium
E. Schizophrenia
D
The primary distinguishing feature of delirium is a course that is typically acute, with rapid deterioration over hours or days, rather than months as with dementia. Also, the severity of delirium tends to fluctuate over the course of hours, with patients appearing quite normal at times and wildly agitated with hallucinations at others. Frequently, extreme changes in psychomotor activity are noted with delirium; although this may also be seen with dementia, it is typically not seen until the latter stages.
The most frequently reported symptom of vulvar cancer is which one of the following? (check one)
A. Longstanding pruritus
B. Bleeding
C. Pain
D. Discharge
E. Dysuria
A
The most common symptom of vulvar cancer is longstanding pruritis. The other symptoms mentioned occur less frequently
Intravenous magnesium is used to correct which one of the following arrhythmias?
A. Wenckebach second-degree heart block
B. Complete heart block
C. Idioventricular rhythm
D. Reentrant supraventricular tachycardia
E. Ventricular tachycardia of torsades de pointes
E
A well-known use of IV magnesium is for correcting the uncommon ventricular tachycardia of torsades de pointes, and acute management of rapid a-fib.
Which one of the following medications is most likely to cause hypokalemia?
A. Albuterol (Proventil, Ventolin)
B. Doxazosin (Cardura)
C. Erythromycin
D. Felodipine (Plendil)
E. Lisinopril (Prinivil, Zestril)
A
β-Agonists activate potassium uptake by the cells. This includes bronchodilators and tocolytic agents. Other agents that can induce hypokalemia include pseudoephedrine and insulin. Thiazides, can also cause hypokalemia as a result of the renal loss of potassium.
A 35-year-old female sees you because she has lost her voice. She has had no recent upper respiratory infection symptoms, cough, or heartburn, and she has not done anything that would strain her voice. Findings are normal on examination of the head and neck. A review of her chart shows this has happened before, but an ear, nose, and throat evaluation found no abnormalities. She also has been seen numerous times in the past few years for headaches, chest pains, abdominal pains, rectal pressure, and vaginal symptoms. Despite several workups and referrals, no definite cause has been found and the symptoms persist. Which one of the following would be the most reasonable plan of action? (check one)
A. Test for food allergies
B. Begin low-dose lorazepam (Ativan)
C. Begin a 6-week trial of a proton pump inhibitor
D. Schedule frequent office visits
D
Somatization disorders should be considered in patients who have a history of various complaints over a several-year period that involve multiple organ systems. There is no test to confirm this diagnosis. It is often intertwined in other psychiatric problems, including anxiety disorder, personality disorder, and depression. Treatment includes testing to make sure that there is nothing physically wrong, while building a trusting relationship with the patient. Once this is accomplished, it is reasonable to discuss the disorder with the patient. Cognitive therapy has been shown to be of value, as well as regularly scheduled office visits for monitoring and support. Medicines for coexisting psychiatric problems also are of benefit. In addition, referral for psychiatric consultation may be worthwhile. Food allergies can cause a variety of symptoms, but usually not to the extent seen with this patient, and testing for this might confuse the issue. Lorazepam may help the symptoms if there is a coexisting anxiety disorder, but it will not address the underlying problem. Laryngeal esophageal reflux can cause hoarseness and will respond to proton pump inhibitors, but given the repetitive nature of her symptoms and the previous negative workups, it is not consistent with the whole picture.
A 15-month-old male is brought to your office 3 hours after the onset of an increased respiratory rate and wheezing. He has an occasional cough and no rhinorrhea. His immunizations are up to date and he attends day care regularly. His temperature is 38.2°C (100.8°F), respiratory rate 42/min, and pulse rate 118 beats/min.
The child is sitting quietly on his mother’s lap. His oxygen saturation is 94% on room air. On examination you note inspiratory crackles in the left lower lung field. The child appears to be well hydrated and the remainder of the examination, including an HEENT examination, is normal. Nebulized albuterol (AccuNeb) is administered and no improvement is noted.
Which one of the following would be most appropriate in the management of this patient? (check one)
A. Laboratory evaluation
B. Inpatient monitoring, with no antibiotics at this time
C. Hospitalization and intravenous ceftriaxone (Rocephin)
D. Close outpatient follow-up, with no antibiotics at this time
E. Oral high-dose amoxicillin (90 mg/kg/day), with close outpatient follow-up
E
The diagnosis of CAP is mostly based on the H&P. Pneumonia should be suspected in any child with fever, cyanosis, and any abnormal respiratory finding in the H&P. Children under 2 years of age who are in day care are at higher risk for developing CAP. Laboratory tests are rarely helpful in differentiating viral versus bacterial etiologies and should not be routinely performed. Outpatient antibiotics are appropriate if the child does not have a toxic appearance, hypoxemia, signs of respiratory distress, or dehydration.
Streptococcus pneumoniae is one of the most common etiologies in this age group, and high-dose amoxicillin is the drug of choice.
During a well child examination, you notice that a 2-month-old male has a flattened left occiput. His records show that his skull was normally shaped at birth. Further evaluation shows that the left frontal region is more prominent than the right, and the left ear is slightly forward of its expected position. The infant seems comfortable rotating his head to either side while being held in his mother’s arms.
Which one of the following would be appropriate at this time? (check one)
A. Recommend that the infant sleep in a prone position, and follow up in 1 month
B. Educate the parents about positioning and follow up in 2 months
C. Order physical therapy
D. Order CT of the head E
E. Refer for surgical evaluation
B
The parallelogram shape of this infant’s head is typical of positional skull deformity aka benign positional molding or occipital plagiocephaly. The incidence of positional skull deformity is increased in children who sleep in the supine position, but switching to prone sleeping is not recommended because this would increase the risk of SIDS. The deformity can be prevented by routine switching of the dependent side of the infant’s head. Supervised “tummy time” for 30–60 minutes each day can also decrease the amount of flattening and can increase the child’s motor development. This condition can prevent correct positioning and is remedied with physical therapy techniques and most infants with positional skull deformity improve within 2–3 months with the institution of positional changes and tummy time. If the condition does not significantly improve after this amount of time, referral to a pediatric neurosurgeon with expertise in craniofacial malformations would be appropriate.
Cranial synostosis is the result of abnormal fusion of one or more of the sutures between the skull bones. Ipsilateral frontal bossing and ear advancement are not seen, resulting in a trapezoid-shaped head.
Which one of the following vaccines is CONTRAINDICATED in immunocompromised adults?
A. Herpes zoster
B. Human papillomavirus
C. Meningococcal
D. Pneumococcal polysaccharide
E. Tdap
A
The herpes zoster vaccine is the only live-attenuated virus vaccine listed, and is therefore the one contraindicated in immunodeficient patients.
HPV, Tdap, meningococcal, and pneumococcal polysaccharide vaccines are not live or live-attenuated vaccines, and may be given to immunocompromised patients
A 5-year-old female presents with a lesion on her forearm. It began as a red macule, turned into a small vesicle that easily ruptured, then dried into a 1-cm honey-colored, crusted lesion seen now. Which one of the following would be the most appropriate therapy? (check one)
A. Oral penicillin V
B. Oral erythromycin
C. Topical disinfectant (e.g., hydrogen peroxide)
D. Topical bacitracin
E. Topical mupirocin (Bactroban)
E
Topical mupirocin is as effective as cephalexin or amoxicillin/clavulanate in the treatment of impetigo, which is most often caused by Staphlococcal species.
Oral penicillin V, oral erythromycin, and topical bacitracin are less effective than mupirocin. Topical disinfectants such as hydrogen peroxide are no more effective than placebo.
A 25-year-old female presents with abdominal pain localized to the right lower quadrant. Which one of the following would be most helpful in diagnosing acute appendicitis? (check one)
A. A CBC
B. Urinalysis
C. Plain abdominal films
D. Abdominal/pelvic ultrasonography
E. Abdominal/pelvic CT
E
A 35-year-old nulligravida sees you for preconception counseling. She has hypothyroidism treated with levothyroxine (Synthroid), and her most recent TSH level was in the therapeutic range. She has no symptoms of hypothyroidism.
Which one of the following is the patient most likely to require if she becomes pregnant? (check one)
A. A decreased dosage of levothyroxine
B. An increased dosage of levothyroxine
C. The addition of liothyronine (Cytomel)
D. Substitution of desiccated thyroid hormone preparation (Armour Thyroid) for the levothyroxine
B
Thyroid hormone requirements increase during pregnancy. Most women with hypothyroidism who become pregnant require an increased levothyroxine dosage. A common recommendation is to have women begin taking nine doses weekly (one extra dose on 2 days of the week) as soon as the pregnancy is confirmed. Thyroid function tests should be repeated regularly throughout the pregnancy to guide additional dosage adjustments.
A 75-year-old white female presents with hyponatremia, with a serum level of 118 mEq/L, a urine osmolality >100 mOsm/kg H2O, and a serum osmolality of 242 mOsm/kg H2O. She complains of some fatigue, but is alert and oriented. Her blood pressure is 136/82 mm Hg. She has normal thyroid, adrenal, cardiac, hepatic, and renal function. You admit her to the hospital for treatment and observation. Which one of the following is the most appropriate initial treatment? (check one)
A. Administration of 3% normal saline
B. Administration of normal saline
C. Free water restriction
D. Demeclocycline (Declomycin)
C
SIADH - can be caused by CNS/lung tumors, infections such as meningitis/pneumonia, medications such as amiodarone, carbamazepine, SSRIs, and chlorpromazine.
In this fairly asymptomatic patient, initial management should be free water restriction. As she is hemodynamically stable, she does not need normal saline. Moreover, administration of normal saline may exacerbate the hyponatremia, as the sodium may be rapidly excreted while the water is retained. If she had a rapid onset and neurologic symptoms such as seizures, hypertonic saline could be given. Correction should be slow, with a goal of no more than a 1-2 mmol/L/hr increase in the sodium level; a normal sodium level should not be reached within the first 48 hours of treatment.
Demeclocycline is appropriate for patients who cannot adhere to the requirement for fluid restriction, or who have recalcitrant hyponatremia despite restriction.
A 64-year-old male comes to your office for evaluation of a persistent rash affecting his groin. It is itchy but not painful and does not affect his daily activities. He has tried over-the-counter antifungal creams without relief. On examination you find well-demarcated, dark red patches in the inguinal region bilaterally. When examined with a Wood’s light the area fluoresces coral-red.
The most effective treatment for this condition is topical? (check one)
A. Ketoconazole (Nizoral)
B. Erythromycin
C. Hydrocortisone
D. Mupirocin (Bactroban)
E. Terbinafine (Lamisil)
B
Coral-red fluorescence on Wood’s light examination is typical of infection with Corynebacterium minutissimum, a condition known as erythrasma. This organism commonly complicates intertrigo, often in the groin or interdigital spaces. Erythromycin is the most effective treatment for this bacterial infection.
A 60-year-old male complains of multiple episodes of lightheadedness over the past 3 months, saying he felt as if he might “pass out” while sitting at his desk. His past medical history and a physical examination are unremarkable. An EKG shows right bundle branch block and left anterior hemiblock.
Which one of the following would be the most appropriate next step?
A. Echocardiography
B. Cardiac event monitoring
C. Hospital admission for pacemaker insertion
D. Immediate initiation of aspirin and metoprolol (Lopressor)
B
This patient’s EKG demonstrates a RBBB and a L anterior hemiblock. This “trifascicular block” puts the patient at risk for tachyarrhythmias and bradyarrhythmias. Given the patient’s complaint of near-syncope, a heart monitoring study would be most appropriate. An echocardiogram may be helpful eventually to assess cardiac function. Although the patient is at risk for heart block, immediate hospitalization is not indicated.
A 5-year-old African-American male presents with behavior problems noted in the first 3 months of kindergarten. The mother explains that the child does not pay attention and often naps in class. He averages 10 hours of sleep nightly and is heard snoring frequently. The mother has a history of attention-deficit disorder and takes atomoxetine (Strattera). The boy’s examination is within normal limits except for his being in the 25th percentile for weight and having 3+ tonsillar enlargement. The most reasonable plan at this point would include which one of the following? (check one)
A. An electroencephalogram
B. Polysomnography
C. Atomoxetine
D. Methylphenidate (Ritalin)
B
OSA is increasingly recognized in children. Peak incidence is in the preschool-age range of 2–5 years when adenotonsillar tissue is greatest in relation to airway size. It is associated with obesity in older children. Common clinical manifestations include snoring with sleep interruptions and respiratory pauses. Polysomnography is the gold standard for the diagnosis.
Although the child has inattention, excessive drowsiness is not seen in attention-deficit/hyperactivity disorder (ADHD) and medications for that condition are not indicated. None of his symptoms suggests a seizure disorder, so an EEG would not be helpful.
A 62-year-old African-American male is admitted to the hospital for the third time in 6 months with heart failure. He has dyspnea with minimal activity. Echocardiography reveals an ejection fraction of 40%.
Which one of the following combinations of medications is most appropriate for long-term management of this patient? (check one)
A. Enalapril (Vasotec) plus digoxin
B. Hydralazine plus isosorbide dinitrate
C. Losartan (Cozaar) plus amlodipine (Norvasc)
D. Spironolactone (Aldactone) plus bisoprolol (Zebeta)
B
The combination of the vasodilators hydralazine + isosorbide dinitrate has been shown to be effective in the treatment of heart failure when standard treatment with diuretics, β-blockers, and ACEi/ARB are insufficient to control symptoms or cannot be tolerated. This combination is particularly effective in African-Americans with NYHA class III or IV heart failure, with advantages including reduced mortality rates and improvement in quality-of-life measures.
Digoxin, a long-time standard for the treatment of heart failure, is useful in reducing the symptoms of heart failure but has not been shown to improve survival.
Amlodipine and other calcium channel blockers do not have a direct role in the treatment of heart failure.
A 36-year-old male presents to the emergency department with disorientation, tachycardia, diaphoresis, and hypertension. According to his family, he has been consuming up to a fifth of vodka daily but abruptly discontinued alcohol consumption 2 days ago. There is no history of additional substance abuse and a urine drug screen is negative.
Which one of the following is most indicated in the management of this patient? (check one)
A. An anticonvulsant
B. A typical antipsychotic
C. A benzodiazepine
D. A centrally-acting α2-agonist
E. Baclofen
C
Psychomotor agitation is experienced by most patients during alcohol withdrawal. Benzodiazepines are clearly the drug class of choice. Providing medication on an as-needed basis rather than on a fixed schedule is generally preferred.
Antipsychotics and butyrophenones (including haloperidol) lower the seizure threshold and should not be used.
For short-term management of status epilepticus, anticonvulsants may be used in conjunction with benzodiazepines. The vast majority of seizures from withdrawal are self-limited and do not require anticonvulsant treatment.
Clonidine and other α2-agonists do reduce minor symptoms of withdrawal, but have not been shown to prevent seizures.
The effectiveness of baclofen in acute alcohol withdrawal is unknown.
Which one of the following is true regarding temporomandibular joint disorder? (check one)
A. Dental splints are the treatment of choice
B. Mandibular clicking is an essential diagnostic element
C. Ultrasonic phonophoresis with cortisone is the treatment of choice
D. The majority of cases resolve without treatment
E. MRI is preferred over CT to confirm the diagnosis
D
TMJ occur in a large number of adults. The etiology is varied, but includes dental malocclusion, bruxism (teeth grinding), anxiety, stress disorders, and, rarely, rheumatoid arthritis.
While dental splints have been commonly recommended, the evidence for and against their use is insufficient to make a recommendation either way.
Physical therapy modalities such as iontophoresis or phonophoresis may benefit some patients, but there is no clearly preferred treatment.
Radiologic imaging is unnecessary in the vast majority of patients, and should therefore be reserved for chronic or severe cases. In fact, the majority of patients with TMJ disorders have spontaneous resolution of symptoms, so noninvasive symptomatic treatments and tincture of time are the best approach for most.
Metformin (Glucophage) should be stopped prior to which one of the following, and withheld until 48 hours after completion of the test? (check one)
A. An upper GI series
B. Abdominal ultrasonography
C. CT angiography
D. MRI of the brain
E. Colonoscopy
C
Even a temporary reduction in renal function, such as occurs after pyelography or angiography, can cause lactic acidosis in patients taking metformin. The drug should be discontinued 48 hours before such procedures and restarted 48 hours after the procedure if renal function is normal.
A previously healthy 29-year-old pediatric nurse has a 3-day history of malaise, arthralgias, and a nonpruritic rash. The rash is a faint, maculopapular, irregular, reticulate exanthem that covers her thighs and the inner aspects of her upper arms. Symmetric synovitis is present in several distal and proximal interphalangeal joints and in her metacarpophalangeal joints. Small effusions, warmth, and tenderness are noted in her left wrist and right elbow. No other joints are affected. The most likely cause of this problem is:
A. Varicella-zoster virus
B. Measles (rubeola) virus
C. Parvovirus B19
D. Human immunodeficiency virus (HIV)
C
Also known as erythema infectiosum or fifth disease, parvovirus B19 is a fairly common cause of an exanthematous rash + arthritis in younger women. This infection should be particularly suspected in health-care workers who have frequent contact with children. The specific characteristics of the rash, the pattern of joint involvement, and the place of employment in an otherwise healthy person all offer clues suggesting parvovirus B19 as the infecting agent. Measles virus, adenovirus, and HIV rarely cause arthritis, although HIV infection can cause a musculoskeletal syndrome later in the disease. Varicella-zoster virus may cause large-joint arthritis, but the rash is distinctively vesicular and pruritic.
Which one of the following is the leading cause of death following bariatric surgery? (check one)
A. Pulmonary embolism
B. Adult respiratory distress syndrome
C. Peritonitis secondary to an anastomotic leak
D. Sepsis related to a wound infection
E. Hemorrhage from an anastomotic ulcer
A
Pulmonary emboli, anastomotic leaks, and respiratory failure are responsible for 80% of deaths in the 30 days following bariatric surgery, with death from pulmonary embolism being the most frequent cause. Wound infections and marginal ulcers are common complications of this type of surgery.
A nurse who completed a hepatitis B vaccine series a year ago is accidentally stuck by a needle that has just been used on a dialysis patient. The patient is known to be HBsAg-positive. Your first response should be to: (check one)
A. Provide reassurance only
B. Test the nurse for hepatitis B antibody
C. Repeat the hepatitis B vaccine series
D. Administer hepatitis B immune globulin (HBIG) only
E. Administer HBIG plus a booster of hepatitis B vaccine
B
The exposed person should be tested for hepatitis B antibodies; if antibody levels are inadequate ( An unvaccinated individual in this same setting should receive HBIG immediately (preferably within 24 hours after exposure) followed by the hepatitis B vaccine series (injection in 1 week or less, followed by a second dose in 1 month and a third dose in 6 months).
A 43-year-old female presents to your office for evaluation of a chronic cough that has been present for the past 6 months. She is not a smoker, and is not aware of any exposure to environmental irritants. She does not have any systemic complaints such as fever or weight loss, and does not have any symptoms of heartburn or regurgitation. She is not on any regular medications.
Auscultation of the lungs and a chest radiograph show no evidence of acute disease. A trial of an inhaled bronchodilator and antihistamine therapy does not improve the patient’s symptoms.
Which one of the following would be the most appropriate next step?
A. A methacholine inhalation challenge test
B. Pulmonary function testing
C. CT of the chest
D. A trial of a proton pump inhibitor
E. 24-hour pH monitoring
D
Gastroesophageal reflux disease (GERD) is one of the most common causes of chronic cough. The cough is thought to be triggered by microaspiration of acidic gastric contents into the larynx and upper bronchial tree.
Aggressive acid reduction using a proton pump inhibitor twice daily before meals for 3–4 months is the best way to demonstrate a causal relationship between GERD and extra-esophageal symptoms.
Methacholine inhalation testing is not necessary in this patient, since symptomatic asthma has been ruled out by the lack of response to bronchodilator therapy. Chest CT and pulmonary function tests are not indicated given the lack of findings from the history, physical examination, and chest film to suggest underlying pulmonary disease. An initial therapeutic trial of proton pump inhibitors is favored over 24-hour pH monitoring because it is less uncomfortable to the patient and has a better clinical correlation.
You see a 16-year-old white female for a preparticipation evaluation for sports, and she asks for advice about the treatment of acne. She has a few inflammatory papules on her face. No nodules are noted. She says she has not tried any over-the-counter acne treatments. Which one of the following would be considered first-line therapy for this condition? (check one)
A. Oral tetracycline
B. Oral isotretinoin (Accutane)
C. Topical sulfacetamide (Sulamyd)
D. Topical benzoyl peroxide
D
Mild acne is limited to a few to several papules and pustules without any nodules.
Moderate acne have several to many papules and pustules with a few to several nodules.
Severe acne have many or extensive papules, pustules, and nodules.
The patient has mild acne according to the classification scheme. Topical treatments including benzoyl peroxide, retinoids, and topical antibiotics are useful first-line agents in mild acne. Topical sulfacetamide is not considered first-line therapy for mild acne. Oral antibiotics are used in mild acne when there is inadequate response to topical agents and as first-line therapy in more severe acne.
Caution must be used to avoid tetracycline in pregnant females.
Oral isotretinoin is used in severe nodular acne, but also must be used with extreme caution in females who may become pregnant. Special registration is required by physicians who use isotretinoin, because of its teratogenicity.
A 78-year-old Hispanic male comes to see you after attending a health fair. He is concerned because he had a prostate-specific antigen (PSA) level of 5.0 ng/mL (N 0.0–4.0). He has never had his PSA checked before. His medical history is significant for class IV heart failure treated with furosemide (Lasix), enalapril (Vasotec), carvedilol (Coreg), digoxin, and spironolactone (Aldactone). His review of systems is positive for longstanding nocturia and gradually worsening weakness of the urinary stream. His physical examination is noteworthy for bibasilar rales, an S3 gallop, and moderate lower extremity edema. His prostate is diffusely large and smooth. His urinalysis is unremarkable. Which one of the following is the most appropriate management for his elevated PSA? (check one)
A. No intervention
B. Repeat testing after a course of antibiotics
C. Referral for a CT scan or MRI of the pelvis
D. Referral for prostate ultrasonography and biopsy
A
The patient described has a life expectancy that makes the risk-benefit ratio for the detection of asymptomatic prostate cancer extremely unfavorable. In addition, a mildly elevated PSA in a 78-year-old with a large prostate is most likely due to benign prostatic hypertrophy.
Which one of the following is the most common cause of recurrent and persistent acute otitis media in children? (check one)
A. Haemophilus influenzae
B. Moraxella catarrhalis
C. Penicillin-resistant Streptococcus pneumoniae
D. Pseudomonas aeruginosa
E. Staphylococcus aureus
C
S. pneumoniae, H. influenzae, and M. catarrhalis are the most common bacterial isolates from the middle ear fluid of children with acute otitis media.
Penicillin-resistant S. pneumoniae is the most common cause of recurrent and persistent acute otitis media.
A 23-year-old female comes to your office 6 days after giving birth to her first child by cesarean section. Her pregnancy was complicated by preeclampsia. During the history she reports brief crying spells, irritability, poor sleep, and nervousness. Her husband notes that “even the littlest thing can set her off.” She has a history of major depression 2 years ago that resolved with psychotherapy and SSRI treatment. She and her husband are concerned that she may be suffering from postpartum depression.
Which one of the following is the greatest risk factor for postpartum depression in this patient? (check one)
A. Operative delivery
B. First pregnancy and delivery
C. Preeclampsia
D. A previous history of depression
D
“Baby blues” begin during the first 2–3 days after delivery and resolve within 10 days; symptoms include brief crying spells, irritability, poor sleep, nervousness, and emotional reactivity. Roughly 8%–10% will progress to a major postpartum depression.
A previous history of MDD significantly increases the risk of developing postpartum depression (RR = 4.5), and a prior episode of postpartum depression is the strongest risk factor for postpartum depression in subsequent pregnancies.
Prenatal and obstetric complications and socioeconomic status have not consistently been shown to be risk factors. First pregnancy is also not a significant risk factor.
A 59-year-old white female has a blood pressure consistently at or above 140/90 mm Hg. Her only other significant medical problem is diabetes mellitus, which is controlled by diet.
Which one of the following is the most clearly established advantage of angiotensin receptor blockers (ARBs) when compared with ACE inhibitors in patients such as this? (check one)
A. Reduced risk of persistent cough
B. Reduced risk of headache
C. Reduced risk of heart failure
D. Improved control of blood pressure
E. Improved lipid profile
A
In multiple studies, angiotensin receptor blockers (ARBs) have been shown to be less likely to cause a chronic cough when compared with ACE inhibitors. Although this is not a life-threatening danger, it is a side effect that can be persistent and lead to discontinuation of medication. Angioedema, a more dangerous side effect, is thought to be ACE-inhibitor specific, though there have been case reports of angioedema associated with ARB use.
Amiodarone (Cordarone) is most useful for which one of the following? (check one)
A. Prophylactic perioperative use for emergency surgery
B. Primary prevention of nonischemic cardiomyopathy
C. Treatment of atrial flutter
D. Treatment of multi-focal premature ventricular contractions following acute myocardial infarction
E. Treatment of sustained ventricular tachyarrhythmias in patients with poor hemodynamic stability
E
Amiodarone - antiarrhythmic useful in the acute management of sustained ventricular tachyarrhythmias, regardless of hemodynamic stability. It is first-line treatment for symptomatic a-fib in patients with LV dysfunction and heart failure.
It has a very limited role in the treatment of atrial flutter.
The only role for prophylactic amiodarone is in the perioperative period of cardiac surgery.
The use of prophylactic antiarrhythmic agents in the face of “warning dysrhythmias” or after MI is no longer recommended. Prophylactic amiodarone is not indicated for primary prevention in patients with nonischemic cardiomyopathy.
A 30-year-old African-American female is being evaluated because of absent menses for the last 6 months. Menarche was at age 12. Her menstrual periods have frequently been irregular, and are accompanied only occasionally by dysmenorrhea. She had her first child 4 years ago, but has not been able to become pregnant since. A physical examination and pelvic examination are unremarkable. A serum pregnancy test is negative, prolactin levels are normal, and LH and FSH levels are both three times normal on two occasions.
These findings are consistent with:
A. hypothalamic amenorrhea
B. ovarian failure
C. pituitary microadenoma
D. polycystic ovary syndrome
B
The history and physical findings in this patient are consistent with all of the conditions listed. However, the elevated FSH and LH indicate an ovarian problem, and this case is consistent with ovarian failure or premature menopause.
Most pituitary tumors associated with amenorrhea produce hyperprolactinemia. Polycystic ovary syndrome usually results in normal to slightly elevated LH levels and tonically low FSH levels. Hypothalamic amenorrhea is a diagnosis of exclusion, and can be induced by weight loss, excessive physical exercise (running, ballet), or systemic illness. It is associated with tonically low levels of LH and FSH.
The mother of a 16-year-old male calls to report that her son has a severe sore throat and has been running a fever of 102°F. Which one of the following additional findings would be most specific for peritonsillar abscess? (check one)
A. A 1-day duration of illness
B. Ear pain
C. Difficulty opening his mouth
D. Hoarseness
E. Pain with swallowing
C
Trismus (difficulty opening mouth) is almost universally present with peritonsillar abscess, while voice changes, otalgia, and odynophagia may or may not be present.
Pharyngotonsillitis and peritonsillar cellulitis may also be associated with these complaints.
Otalgia is common with peritonsillar abscess, otitis media, temporomandibular joint disorders, and a variety of other conditions.
Peritonsillar abscess is rarely found in patients who do not have at least a 3-day history of progressive sore throat.
A patient presenting with severe carbon monoxide poisoning should be treated with: (check one)
A. inhaled helium
B. supplemental oxygen
C. intravenous calcium gluconate
D. intravenous iron
E. intravenous magnesium
B
Patients with carbon monoxide poisoning should be treated immediately with normobaric oxygen, which speeds up the excretion of carbon monoxide.
A 57 yo M presents to the ED after several episodes of vomiting preceded by moderately severe epigastric pain. He says the vomitus looked like coffee grounds. He tells you he has had “heartburn” in the past that was sometimes severe, and occasionally associated with vomiting, but these episodes were almost always relieved by oral antacids. This problem was exacerbated recently after he began taking ketorolac for moderate arthritic pain in his knees and hands. His PMHx and ROS reveal no major comorbid disorders.
BP is 125/82 mm Hg, HR 95 beats/min with no signs of shock. Hg 9.5 g/dL (N 13.0–18.0). He is admitted to the hospital and placed on a PPI infusion. Upper GI endoscopy performed within 3 hours of admission shows no blood in the upper GI tract, but reveals a Mallory-Weiss tear and a stomach ulcer containing a dark spot in an otherwise clear base.
Management at this time should include which one of the following?
A. Transfusion with whole blood
B. Repeat endoscopy within 24 hours
C. Arteriography
D. Continued in-hospital observation for at least 72 hours
E. Discharge from the hospital on oral PPI therapy
E
Patients with low-risk peptic ulcer bleeding based on clinical and endoscopic criteria can be discharged from the hospital on PO PPI thearpy on the same day as endoscopy.
Routine second-look endoscopy is not recommended in patients with upper gastrointestinal bleeding who are not considered to be at high risk for rebleeding.
Arteriography with embolization is indicated only in patients with persistent bleeding.
A 25-year-old female comes to your office requesting a referral to an otolaryngologist for surgery on her nose. She states that her nose is too large and that “something must be done.” She has already seen multiple family physicians, as well as several otolaryngologists. She is 168 cm (66 in) tall and weighs 64 kg (141 lb). A physical examination is normal, and even though she initially resists a nasal examination, it also is normal. The size of her nose is normal.
Which one of the following is the most likely cause of this patient’s concern about her nose? (check one)
A. Obsessive-compulsive disorder
B. Anorexia nervosa
C. Depression
D. Body dysmorphic disorder
D
Body dysmorphic disorder is an increasingly recognized somatoform disorder where patients have a preoccupation with imagined defects in appearance, which causes emotional stress. Body dysmorphic disorder may coexist with anorexia nervosa, atypical depression, obsessive-compulsive disorder, and social anxiety. Cosmetic surgery is often sought. SSRIs and behavior modification may help, but cosmetic procedures are rarely helpful.
A 49-year-old uninsured female with diabetes mellitus presents with painful burning of her feet, particularly at night. She has tried ibuprofen and acetaminophen without relief. Her last hemoglobin A1c was 7.1%. Her medications include metformin (Glucophage), glipizide (Glucotrol), lisinopril (Prinivil, Zestril), and lovastatin (Mevacor).
Which one of the following would be the best choice to treat her foot pain? (check one)
A. Amitriptyline
B. Topiramate (Topamax)
C. Fluoxetine (Prozac)
D. Lamotrigine (Lamictal)
A
First-line treatment for diabetic peripheral neuropathy is tricyclic antidepressants. Anticonvulsants are second line and opioids are third line. Many medications have been found to be effective, including the tricyclics, duloxetine, pregabalin, oxycodone, and tramadol.
Among the tricyclics, amitriptyline, imipramine, and nortriptyline have been found to be the most effective. For an uninsured patient, the tricyclics are also the most affordable.
A 42-year-old female is found to have a thyroid nodule during her annual physical examination. Her TSH level is normal. Ultrasonography of her thyroid gland shows a solitary nodule measuring 1.2 cm.
Which one of the following would be most appropriate at this point? (check one)
A. A radionuclide thyroid scan
B. A fine-needle aspiration biopsy of the nodule
C. Partial thyroidectomy
D. Total thyroidectomy
E. Reassurance
B
All patients who are found to have a thyroid nodule should have their TSH measured. Patients with a suppressed TSH should be evaluated with a radionuclide thyroid scan; nodules that are “hot” (show increased isotope uptake) are almost never malignant and fine-needle aspiration biopsy is not needed. For all other nodules, the next step in the workup is a fine-needle aspiration biopsy to determine whether the lesion is malignant.
A healthy 24-year-old male presents with a sore throat of 2 days’ duration. He reports mild congestion and a dry cough. On examination, his temperature is 37.2°C (99.0°F). His pharynx is red without exudates, and there are no anterior cervical nodes. His tympanic membranes are normal, and his chest is clear.
You would do which one of the following?
A. Treat with analgesics and supportive care
B. Treat with azithromycin (Zithromax)
C. Perform a throat culture and begin treatment with penicillin
D. Perform a rapid strep test
A
CDC Centor Criteria for predicting streptococcal pharyngitis. These include
- tonsillar exudates
- tender anterior cervical lymphadenopathy
- absence of cough
- history of fever
Patients with four positive criteria should be treated with antibiotics
those with three positive criteria should be tested and treated if positive
those with 0–1 positive criteria should be treated with analgesics and supportive care only. This patient has only one of the Centor criteria, and according to the panel should not be tested or treated with antibiotics.
A 36-year-old female consults you because of concerns about “fatigue.” After carefully reviewing her history and performing a physical examination, which one of the following would be LEAST valuable in assessing this patient? (check one)
A. A baseline serum cortisol level
B. An erythrocyte sedimentation rate
C. A complete metabolic panel
D. A TSH level
E. A pregnancy test
A
In patients with fatigue, laboratory studies should include ESR, CMP, TSH level, CBC and a UA. A pregnancy test should be ordered for women of childbearing age.
A baseline cortisol level would be valuable only in patients with significant findings of Addison’s disease.
No other tests have been shown to be useful unless a specific medical condition is suspected.
A 68-year-old female is being monitored in the hospital after elective surgery. On her third postoperative day she suddenly develops hypoxia, fever, tachycardia, and hypotension. You institute high-rate intravenous fluids and empiric antibiotics. However, approximately 2 hours into this therapy, her blood pressure remains at 80 mm Hg systolic with sluggish urine output.
Which one of the following hormones should be assessed at this time? (check one)
A. Aldosterone
B. Catecholamines
C. Cortisol
D. Renin
E. TSH
C
It has been recognized that patients suffering from a critical illness with an exaggerated inflammatory response often have a relative cortisol deficiency. Clinically, this can cause hypotension that is resistant to IV fluid resuscitation. Evidence is mounting that survival is increased if these patients are treated with IV corticosteroids during acute management. Cortisol levels can be assessed with a single serum reading, or by the change in the cortisol level after stimulation with cosyntropin (referred to as Δcortisol).
The other hormones listed are not important for the acute management of a critically ill patient.
An overweight 13-year-old male presents with a 3-week history of right lower thigh pain. He first noticed the pain when jumping while playing basketball, but now it is present even when he is just walking. On examination he can bear his full weight without an obvious limp. There is no localized tenderness, and the patella tracks normally without subluxation. Internal rotation of the hip is limited on the right side compared to the left. Based on the examination alone, which one of the following is the most likely diagnosis? (check one)
A. Avascular necrosis of the femoral head (Legg-Calvé-Perthes disease)
B. Osteosarcoma
C. Meralgia paresthetica
D. Pauciarticular juvenile rheumatoid arthritis
E. Slipped capital femoral epiphysis
E
This is a classic presentation for slipped capital femoral epiphysis (SCFE) in an adolescent male who has probably had a recent growth spurt. Pain with activity is the most common presenting symptom, as opposed to the nighttime pain that is typical of malignancy. Obese males are affected more often. The pain is typically in the anterior thigh, but in a high percentage of patients the pain may be referred to the knee, lower leg, or foot. Limited internal rotation of the hip, especially with the hip in 90°; flexion, is a reliable and specific finding for SCFE and should be looked for in all adolescents with hip, thigh, or knee pain.
Meralgia paresthetica is pain in the thigh related to entrapment of the lateral femoral cutaneous nerve, often attributed to excessively tight clothing. Legg-Calvé-Perthes disease (avascular or aseptic necrosis of the femoral head) is more likely to occur between the ages of 4 and 8 years. Juvenile rheumatoid arthritis typically is associated with other constitutional symptoms including stiffness, fever, and pain in at least one other joint, with the pain not necessarily associated with activity.
Which one of the following variables is the most important risk factor for being a victim of domestic abuse? (check one)
A. Educational background
B. Psychological problems
C. Race
D. Gender
E. Socioeconomic status
D
Domestic violence cuts across all racial, socioeconomic, religious, and ethnic lines. The only consistent risk factor for being a victim is female gender.
Of the following antidepressants, which one is LEAST likely to cause drug interactions? (check one)
A. Citalopram (Celexa)
B. Fluoxetine (Prozac)
C. Paroxetine (Paxil)
D. Mirtazapine (Remeron)
A
Like all drugs, SSRIs have significant side effects, including inhibition of the cytochrome P-450 system. However, citalopram is least likely to inhibit this system, making it a preferred SSRI for patients taking multiple medications for other illnesses.
28-year-old male presents with the recent onset of intermittent urethral discharge accompanied by dysuria. He is heterosexual, has no prior history of a sexually transmitted infection, and acquired a new sexual partner a month ago. He has no regional lymphadenopathy or ulcers, and gentle milking of the urethra produces no discharge. Evaluation of a first-void urine specimen, however, reveals 15 WBCs/hpf. You treat him with oral azithromycin (Zithromax), 1 g in a single dose, and ceftriaxone (Rocephin), 125 mg intramuscularly. Test results for gonorrhea, Chlamydia, syphilis, HIV, and hepatitis B are negative.
He returns 2 months later because his urethral discharge has persisted. He reports no relationships with a different sexual partner, and is confident that his current partner has only had sexual contact with him. You repeat the previous tests and again treat him with oral azithromycin.
According to CDC testing and treatment guidelines, which one of the following drugs should be added to his treatment regimen? (check one)
A. Metronidazole (Flagyl)
B. Amoxicillin/clavulanate (Augmentin)
C. Ciprofloxacin (Cipro)
D. Trimethoprim/sulfamethoxazole (Bactrim, Septra)
E. Cefixime (Suprax)
A
The initial workup for urethritis in men includes G+C testing of the penile discharge/urine or UA with microscopy if no discharge is present, VDRL or RPR testing for syphilis, and HIV and hepatitis B testing.
Empiric treatment for men with a purulent urethral discharge or a positive urine test (+leukocyte esterase or ≥10 WBCs/hpf in the first-void urine sediment) includes azithromycin OR doxycycline PLUS ceftriaxone OR cefixime
If the patient presents with the same complaint within 3 months, and does not have a new sexual partner, the tests obtained at his first visit should be repeated, and cultures for Mycoplasma or Ureaplasma and Trichomonas from the urethra or urine should be obtained. Treatment should include azithromycin OR doxycycline PLUS metronidazole
Which one of the following is an appropriate rationale for antibiotic treatment of Bordetella pertussis infections? (check one)
A. It delays progression from the catarrhal stage to the paroxysmal stage
B. It reduces the severity of symptoms
C. It reduces the duration of illness
D. It reduces the risk of transmission to others
E. It reduces the need for hospitalization
D
Antibiotics treatment for pertussis is effective for eradicating bacterial infection, which is important for disease control because it reduces infectivity. However, it is not for reducing the duration or severity of the disease.
Azithromycin for 3–5 days or clarithromycin for 7 days
Children under 1 month of age should be treated with azithromycin, as there is an association between erythromycin and hypertrophic pyloric stenosis in young infants.
TMP/SMX can be used in patients who are unable to take macrolides or where macrolide resistance may be an issue, but should not be used in children
A 26-month-old child presents with a 2-day history of 6–8 loose stools per day and a low-grade fever. When evaluating the child to determine whether he is dehydrated, which one of the following would NOT be useful in assessing dehydration?
A. Skin turgor
B. Capillary refill time
C. Respiratory rate and pattern
D. The BUN/creatinine ratio
E. The serum bicarbonate level
D
The most useful findings for identifying dehydration are prolonged capillary refill time, abnormal skin turgor, abnormal respiratory pattern, and low serum bicarb (
Unlike in adults, calculation of the BUN/creatinine ratio is not useful in children. Although the normal BUN level is the same for children and adults, the normal serum creatinine level changes with age in children.
A 52-year-old female presents to the emergency department with a complaint of chest pain. The symptoms began 2 hours ago while she was shopping. She describes the pain as a tightness on the left side of her chest that radiates to her left shoulder. She has some shortness of breath with the pain, but no nausea or diaphoresis. Her past medical history is significant for panic disorder.Her vital signs and a physical examination are within normal limits.Which one of the following would be the most appropriate next step in the management of this patient? (check one)
A. Admit to a monitored bed for further evaluation
B. Obtain a CBC, a blood chemistry profile, liver function tests, and an EKG
C. Administer a short-acting benzodiazepine and observe for 60 minutes
D. Consult with a cardiologist for immediate heart catheterization
E. Obtain a troponin I measurement and an EKG
E
This patient has symptoms that suggest acute coronary syndrome, which includes chest pain with activity that radiates to the shoulder. An EKG is essential early in the evaluation of a patient with chest pain, and the initial evaluation should also include a troponin I measurement.
The patient should neither be admitted nor given a benzodiazepine until the EKG is performed. The diagnosis of acute coronary syndrome should be established prior to heart catheterization. Other laboratory tests may be appropriate, but they are not the most important initial tests.
A 67-year-old female presents with the inability to smell. She is in good health, and her only medical problem is osteoporosis, treated with alendronate (Fosamax). She says she has no sinus or nasal symptoms. A physical examination is normal including an ear, nose, and throat examination. Which one of the following would be most appropriate at this point?
A. Discontinuing the alendronate
B. An anti-tissue transglutaminase antibody test
C. A serum vitamin D level
D. MRI of the brain
D
Certain drugs can affect taste more than smell, but this does not include the bisphosphonates. Olfactory disorders may be associated with deficiencies of vitamins A, B6, B12, and trace metals, but not with vitamin D deficiency. Celiac disease is not known to cause a decreased ability to smell. Rare tumors involving the olfactory region of the brain can affect smell, and are best detected by MRI.
Which one of the following patients is unlikely to benefit from vaccination against hepatitis A? (check one)
A. A missionary traveling to Mexico
B. A man who has sex with men
C. A methamphetamine addict
D. A patient with chronic hepatitis
E. A 40-year old recent immigrant from India
E
Each of the individuals listed is at increased risk for hepatitis A infection or its complications, except for the Indian immigrant. Hepatitis A is so prevalent in developing countries such as India that virtually everyone is infected by the end of childhood, and therefore immune. Infection with hepatitis A confers lifelong immunity, so an adult from a highly endemic area such as India has little to gain from vaccination.
A 32-year-old meat cutter comes to your office with persistent symptoms of nausea, vomiting, and diarrhea which began about 36 hours ago on the last day of a 5-day Caribbean cruise. His wife was sick during the first 2 days of the cruise with similar symptoms. On the ship, they both ate the “usual foods” in addition to oysters. Findings on examination are negative, and a stool specimen is negative for white cells. Which one of the following is the most likely cause of his illness? (check one)
A. Escherichia coli
B. Rotavirus
C. Norwalk virus
D. Hepatitis A
E. Giardia species
C
Recent reports of epidemics of gastroenteritis on cruise ships are consistent with Norwalk virus infections due to waterborne or foodborne spread. In the United States, these viruses are responsible for about 90% of all epidemics of nonbacterial gastroenteritis.
The Norwalk-like viruses are common causes of waterborne epidemics of gastroenteritis, and have been shown to be responsible for outbreaks in nursing homes, on cruise ships, at summer camps, and in schools.
Symptomatic treatment is usually appropriate.
An anxious 62-year-old white male comes to the emergency department complaining of extreme shortness of breath and a cough producing blood-tinged sputum. The patient denies chest pain and fever. On examination he is afebrile and has expiratory wheezes and a few rales throughout the chest. The heart is normal except for a rapid rate and an S3 gallop. A chest radiograph reveals a right pleural effusion with enlargement of the cardiac silhouette and redistribution of blood flow to the upper lobes. Which one of the following tests would be best for confirming the diagnosis? (check one)
A. Troponin I
B. BNP
C. D-dimer
D. CT angiography of the chest
E. Arterial blood gases
B
This patient has heart failure with a bronchospastic component. The S3 gallop occurs with a dilated LV and a R-sided pleural effusion, which are common in heart failure. A BNP level is useful in differentiating cardiac vs pulmonary diseases, while a troponin I level is helpful in assessing for cardiac ischemia. Arterial blood gasses are not useful in confirming the diagnosis. A CT angiogram of the chest would be useful for diagnosing pulmonary embolism. A d-dimer test is helpful to rule out venous thromboembolic disease.
An 18-year-old male presents with a sore throat, adenopathy, and fatigue. He has no evidence of airway compromise. A heterophil antibody test is positive for infectious mononucleosis.
Appropriate management includes which one of the following? (check one)
A. A corticosteroid
B. An antihistamine
C. An antiviral agent
D. Strict bed rest
E. Avoidance of contact sports
E
Although most patients will not have a palpably enlarged spleen on examination, it is likely that all, or nearly all, patients with mononucleosis have splenomegaly. In a small study, 100% of patients hospitalized for mononucleosis had an enlarged spleen by US exam, whereas only 17% of patients with splenomegaly have a palpable spleen. Patients should be advised to avoid contact- or collision-type activities for 3–4 weeks because of the increased risk of rupture.
The cornerstone of treatment for mononucleosis is supportive, including hydration, NSAIDs, and throat sprays or lozenges.
A 34-year-old female with menorrhagia is found to have iron deficiency anemia. Which one of the following is true regarding the treatment of this problem with oral iron? (check one)
A. An acidic environment enhances the absorption of iron from the gastrointestinal tract
B. Iron is absorbed better if taken with food
C. Diarrhea is a common complication
D. Iron supplementation can be discontinued once the hemoglobin reaches a normal level
E. Sustained-release formulations increase the total amount of iron available for absorption
A
Oral iron is absorbed better with an acidic gastric environment, which can be accomplished with the concomitant administration of vitamin C. Oral iron absorption is improved if the iron is taken on an empty stomach, but this may not be well tolerated because gastric irritation is a frequent side effect. Constipation also is common with oral iron therapy. Iron therapy should be continued for several months after the hemoglobin reaches a normal level, in order to fully replenish iron stores. Sustained-release oral iron products provide a decreased amount of iron for absorption.
Agents that raise gastric pH, such as antacids, proton pump inhibitors, and H2 blockers, should be avoided if possible.
When obtaining informed consent from a patient, which one of the following is NOT required for a patient to legally have decision-making capacity? (check one)
A. The absence of mental illness
B. The ability to express choice
C. The ability to understand relevant information
D. The ability to engage in reasoning
E. The ability to appreciate the significance of information and its consequences
A
Patients with mental illness may have decision-making capacity if they are able to understand and communicate a rational decision. The key factors to consider in determining decision-making capacity include whether the patient can express a choice, understand relevant information, appreciate the significance of the information and its consequences, and engage in reasoning as it relates to medical treatment.
A 23-year-old gravida 1 para 0 at 36 weeks gestation presents to the office complaining of ankle swelling and headache for the past 2 days. She denies any abdominal pain or visual disturbances. On examination you note a fundal height of 35 cm, a fetal heart rate of 140 beats/min, 2+ lower extremity edema, and a blood pressure of 144/92 mm Hg. A urine dipstick shows 1+ proteinuria. A cervical examination reveals 2 cm dilation, 90% effacement, –1 station, and vertex presentation.
Which one of the following is the most appropriate next step in the management of this patient? (check one)
A. Laboratory evaluation, fetal testing, and 24-hour urine for total protein
B. Ultrasonography to check for fetal intrauterine growth restriction
C. Initiation of antihypertensive treatment
D. Immediate induction of labor
E. Immediate cesarean delivery
A
This patient most likely has preeclampsia, which is defined as an elevated blood pressure and proteinuria after 20 weeks gestation. The patient needs further evaluation, including a 24-hour urine for quantitative measurement of protein, blood pressure monitoring, and laboratory evaluation that includes hemoglobin, hematocrit, a platelet count, and serum levels of transaminase, creatinine, albumin, LDH, and uric acid. A peripheral smear and coagulation profiles also may be obtained. Antepartum fetal testing, such as a nonstress test to assess fetal well-being, would also be appropriate.
A 78-year-old male comes to your office with a 3-day history of pain in the right side of his chest. The pain is described as burning and intense. Two days ago he noted a rash at that site. Examination reveals groups of vesicles on an erythematous base in a T-5 dermatome distribution on the right. Which one of the following would be the most appropriate treatment to minimize the chance of post-herpetic neuralgia?
A. Famciclovir (Famvir)
B. Prednisone
C. Capsaicin (Zostrix)
D. Carbamazepine (Tegretol)
A
The key indicator of postherpetic neuralgia is persistent pain 3–6 months after an episode of herpes zoster. Studies show that patients who present for treatment of herpes zoster within 72 hours will benefit from antiviral therapy such as famciclovir to reduce the pain and decrease the risk of postherpetic neuralgia.
Treating zoster pain with tricyclic antidepressants in low dosage (10–25 mg amitriptyline) may also decrease risk. While steroids added to antiviral therapy may be of benefit in short-term therapy, they do not reduce pain at 6 months.
A 24-year-old female has noted excessive hair loss over the past 2 months, with a marked increase in hairs removed when she brushes her hair. She delivered a healthy baby 5 months ago. She is on no medications, and is otherwise healthy. Examination of her scalp reveals diffuse hair thinning without scarring. An evaluation for thyroid dysfunction and iron deficiency is negative.Which one of the following is the most likely cause of her hair loss? (check one)
A. Telogen effluvium
B. Anagen effluvium
C. Alopecia areata
D. Female-pattern hair loss
E. Discoid lupus erythematosus
A
The recycling of scalp hair is an ongoing process, with the hair follicles rotating through three phases. The actively growing anagen-phase hairs give way to the catagen phase, during which the follicle shuts down, followed by the resting telogen phase, during which the hair is shed.
This patient most likely has a telogen effluvium, a nonscarring, shedding hair loss that occurs when a stressful event, such as a severe illness, surgery, or pregnancy, triggers the shift of large numbers of anagen-phase hairs to the telogen phase. Telogen-phase hairs are easily shed. Telogen effluvium occurs about 3 months after a triggering event. The hair loss with telogen effluvium lasts 6 months after the removal of the stressful trigger.
Anagen effluvium is the diffuse hair loss that occurs when chemotherapeutic medications cause rapid destruction of anagen-phase hair.
Alopecia areata - causes round patches of hair loss, is felt to have an autoimmune etiology.
Female-pattern hair loss affects the central portion of the scalp, and is not associated with an inciting trigger or shedding.
Discoid lupus erythematosus causes a scarring alopecia.
Current U.S. Preventive Services Task Force recommendations for preventing dental caries in preschool-aged children include which one of the following? (check one)
A. Primary care clinicians should prescribe oral fluoride at currently recommended doses to all preschool-aged children
B. Oral fluoride is not necessary if the primary water source contains adequate fluoride
C. Oral fluoride supplementation should begin at birth when indicated
D. Evidence for fluoride supplementation is insufficient to recommend for or against its use
B
oral fluoride supplementation at currently recommended dosages to preschool-aged children older than 6 months of age whose primary water source is deficient in fluoride.
A 41-year-old male presents with a complaint of headaches for the past 6 weeks. He has severe, sharp, right-sided periorbital pain 3–4 days each week. When these headaches occur his right eye gets watery, his right nostril feels clogged, and his forehead feels sweaty. When he gets the headaches he takes four 200-mg ibuprofen tablets and goes into a dark, quiet room. The headaches usually resolve in about 90 minutes. Currently he is feeling well and his examination is completely normal.
What type of headache does he most likely have?
(check one)
A. Medication overuse headache
B. Migraine
C. Paroxysmal hemicrania
D. Temporal arteritis
E. Cluster headache
E
- Cluster headache features
- male
- severe, sharp, continuous unilateral pain that lasts from 15 minutes to 3 hours; generally incapacitating
- headaches are associated with at least one of the following ipsilateral signs: conjunctival injection, lacrimation, nasal congestion, miosis or ptosis, eye edema, and forehead and facial sweating.
- can occur from every other day up to 8 times a day, often in cycles for 4–12 weeks.
- respond to most of the same medications as migraine (DHE, ergotamines, triptans) and 100% oxygen therapy.
- Paroxysmal hemicranias
- very unusual
- present with a similar type of pain as cluster HA, but the attacks are usually short
- more common in women
- Medication rebound headaches
- diffuse, bilateral, almost daily headaches.
- occur in people who are overusing medications, and they tend to get worse with physical or mental exertion.
- Temporal arteritis
- usually occurs in older adults
- Migraines
- often unilateral but they are usually pulsatile
- associated with nausea and vomiting or photophobia and phonophobia.
A 32-year-old white primigravida has a stillbirth at 33 weeks gestation. Which one of the following is the most likely cause? (check one)
A. Infection
B. Placental disease
C. A fetal structural disorder
D. A hypertensive disorder
B
placental abnormalities and obstetric complications were the largest category of causes of stillbirth in white women, and this was even more true after 32 weeks gestation. Other important causes included infection and fetal defects. More than one cause was found in one-third of cases.
A 56-year-old white male reports lower leg claudication that occurs when he walks approximately one block, and is relieved by standing still or sitting. He has a history of diabetes mellitus and hyperlipidemia. His most recent hemoglobin A 1c level was 5.9% and his LDL-cholesterol level at that time was 95 mg/dL. Current medications include glyburide (DiaBeta), metformin (Glucophage), simvastatin (Zocor), and daily aspirin. He stopped smoking 1 month ago and began a walking program. A physical examination is normal, except for barely palpable dorsalis pedis and posterior tibial pulses. Femoral and popliteal pulses are normal. Noninvasive vascular studies of his legs show an ankle-brachial index of 0.7 bilaterally, and decreased flow.
Which one of the following would be most appropriate for addressing this patient’s symptoms? (check one)
A. Fish oil
B. Warfarin (Coumadin)
C. Cilostazol (Pletal)
D. Dipyridamole (Persantine)
E. Clopidogrel (Plavix)
C
Cilostazol has been shown to help with intermittent claudication.
A 63-year-old male with a history of alcoholism and compensated hepatic cirrhosis asks if there are pain medications he can use to treat his chronic low back pain and knee and hand osteoarthritis. He also has occasional headaches. He has not used alcohol for several years.
Which one of the following medications is CONTRAINDICATED in this patient? (check one)
A. Acetaminophen
B. Gabapentin (Neurontin)
C. Naproxen
D. Pregabalin (Lyrica)
E. Tramadol (Ultram)
C
Patients with chronic mild liver disease may take NSAIDs, but they should be avoided in all patients with cirrhosis, due to the risk of precipitating hepatorenal syndrome.
Pregabalin and gabapentin are not metabolized by the liver and can be quite helpful.
Acetaminophen, while toxic in high doses, can be used safely in dosages of 2–3 g/day.
Tramadol is also safe in patients with cirrhosis.
A 52-year-old male requests “everything you’ve got” to help him stop smoking. You review common barriers to quitting and the benefits of cessation with him, and develop a plan that includes follow-up. He chooses to start varenicline (Chantix) to assist with his efforts, and asks about also using nicotine replacement.
Which one of the following would be accurate advice?
A. Combining these medications has not proven to be beneficial
B. The addition of transdermal nicotine, but not nicotine gum, has proven benefits
C. The combination is highly efficacious
D. Nicotine replacement doses need to be doubled in a patient taking varenicline
E. The combination of nicotine and varenicline is potentially lethal
A
Varenicline works by binding to nicotine receptors in the brain, providing much lower stimulation than nicotine itself would. This has the effect of reducing the reinforcement and reward that smoking provides to the brain. However, varenicline also blocks the benefit a patient would receive from nicotine replacement products. Studies have shown that using nicotine replacement products concurrently with varenicline leads to an increase in nausea, headaches, dizziness, and fatigue.
You would recommend pneumococcal vaccine for which one of the following? (check one)
A. A 20-year-old male who smokes 1 pack of cigarettes daily
B. A 52-year-old male with type 2 diabetes mellitus who received pneumococcal vaccine 6 years ago
C. A 60-year-old male who is a long-term resident of a nursing home because of a previous stroke, and who received pneumococcal vaccine at age 54
D. A 62-year-old male with chronic renal failure who received pneumococcal vaccine at age 50 and age 55
E. A 71-year-old male with no medical problems who received pneumococcal vaccine at age 65
A
All persons between the ages of 19 and 64 who smoke should receive this vaccine. One-time revaccination after 5 years is recommended for persons with chronic renal failure, asplenia (functional or anatomic), or other immunocompromising conditions.
You have just diagnosed post-traumatic stress disorder in a 32-year-old male. You immediately begin a program of patient education for him and his family, and connect them with a support group. Since his symptoms are quite severe you decide to begin pharmacotherapy before initiating trauma-focused psychotherapy.
Based on available evidence, which one of the following medications is the best INITIAL treatment choice? (check one)
A. Sertraline (Zoloft)
B. Amitriptyline
C. Phenelzine (Nardil)
D. Alprazolam (Xanax)
E. Haloperidol (Haldol)
A
SSRIs/ sertraline - broadest range of efficacy in treating PTSD since they are able to reduce all three clusters of PTSD symptoms (re-experiencing, numbing, hyperarousal)
TCAs/amitriptyline - modest lessening of the symptoms of reexperiencing, with minimal or no effect on avoidance or arousal symptoms.
MAOi/ phenelzine have shown moderate to good improvement in reexperiencing and avoidance symptoms, but little improvement in hyperarousal.
Benzodiazepines/ alprazolam have been used to treat PTSD, but their efficacy against the major symptoms has not been proven in controlled studies.
In a patient with microcytic anemia, which one of the following patterns of laboratory abnormalities would be most consistent with iron deficiency as the underlying cause? (check one)
A. Ferritin low, total iron binding capacity (TIBC) low, serum iron low
B. Ferritin low, TIBC low, serum iron high
C. Ferritin low, TIBC high, serum iron low
D. Ferritin high, TIBC low, serum iron low
C
Ferritin and serum iron levels fall with iron deficiency. Total iron binding capacity rises, indicating a greater capacity for iron to bind to transferrin (the plasma protein that binds to iron for transport throughout the body) when iron levels are low.
For most patients, which one of the following is the most effective treatment for anemia of chronic disease?
A. Elemental iron
B. Erythropoietin
C. Prednisone
D. Optimal management of the underlying disorder
E. Combined therapy with oral iron, vitamin B12, folic acid, and erythropoietin 0.3%/dexamethasone 0.1% (Ciprodex) topically
D
There is no specific therapy for anemia of chronic disease except to manage or treat the underlying disorder. Iron therapy is of no benefit, but erythropoietin may be helpful in some patients. There is no available data to suggest that combination therapy or prednisone is beneficial for this disorder.
Brain natriuretic peptide (BNP) is a marker for which one of the following? (check one)
A. Renal failure
B. Acute adrenal insufficiency
C. Cerebrovascular accident
D. Heart failure
E. Ureteral obstruction
D
BNP is synthesized, stored, and released by the ventricular myocardium in response to volume expansion and pressure overload. It is a marker for heart failure. This hormone is highly accurate for identifying or excluding heart failure, as it has both high sensitivity and high specificity. BNP is particularly valuable in differentiating cardiac causes of dyspnea from pulmonary causes.
A 27-year-old white male construction worker suffers from severe plaque-type psoriasis that has required systemic therapy. Which one of the following is associated with this condition? (check one)
A. A reduced overall risk of cardiovascular mortality
B. A decreased risk of skin cancer with successful treatment
C. A low likelihood of recurrence with successful treatment
D. An increased risk for the condition in the children of affected individuals
E. Low body mass index and difficulty maintaining weight
D
Psoriasis is a genetic inflammatory condition that has been associated with a significant risk of cardiovascular morbidity and mortality. Children of patients with the disorder are at increased risk, especially if both parents have the disorder. Life expectancy is somewhat reduced in patients with severe psoriasis, particularly if the disease had an early onset.
Plaque psoriasis is usually a lifelong disease; this is in contrast to guttate psoriasis, which may be self-limited and never recur.
Cigarette smoking may increase the risk of developing psoriasis. Psoriasis is also associated with an increased likelihood of obesity, diabetes mellitus, and metabolic syndrome.
Studies indicate that patients most frequently want physicians to ask about their spiritual beliefs in which one of the following situations? (check one)
A. When being treated for a potentially fatal illness
B. During the annual preventive visit
C. During the initial office visit with the physician
D. Only if specifically requested by the patient, a family member, their minister, or a chaplain
E. When prayer is suggested by the patient or physician
A
Patients often welcome spiritual discussion, depending on the situation. The percentage that welcome this discussion increases with the severity of illness, and is greatest among those who are very seriously ill with a potentially fatal disease. Spiritual inquiry during medical care should focus on understanding, compassion, and hope, and should be directed toward individuals who suffer from serious illness.
A 46-year-old white female complains of a 3-month history of hoarseness and nocturnal wheezing. On further questioning, she tells you that she has to clear her throat repeatedly and feels like she has something stuck in her throat.
These symptoms are most likely related to: (check one)
A. thyroid disease
B. gastroesophageal reflux disease
C. sinusitis
D. tracheal stenosis
B
Acid laryngitis is a group of respiratory symptoms related to gastroesophageal reflux disease. The symptoms of hoarseness (especially in the morning), a repeated need to clear the throat, and nocturnal or early morning wheezing may occur singly or in varying combinations, and are believed to be caused by gastric contents irritating the larynx and hypopharynx.
Thyroid disease, sinusitis, and tracheal stenosis can produce one or more of the symptoms described, but not all of them.
A 54-year-old male sees you for a 6-month follow-up visit for HTN. He feels well, but despite the fact that he takes his medications faithfully, his BP averages 150/90 mm Hg. He has had an intensive workup for HTN in the recent past, with normal repeat laboratory results, including a CBC, serum creatinine, an electrolyte panel, and a urinalysis. His medications include chlorthalidone, 12.5 mg daily; carvedilol (Coreg), 25 mg twice daily; amlodipine (Norvasc), 10 mg daily; and lisinopril (Prinivil, Zestril), 40 mg daily. He has been intolerant to clonidine (Catapres) in the past.
A
Which one of the following medication changes would be most reasonable? (check one)
A. Adding isosorbide mononitrate (Imdur)
B. Adding spironolactone (Aldactone)
C. Substituting furosemide (Lasix) for chlorthalidone
D. Substituting losartan (Cozaar) for lisinopril
B
Spironolactone is recommended for treating resistant HTN, even when hyperaldosteronism is not present.
A longer-acting diuretic such as chlorthalidone is also recommended for treating resistant HTN, particularly in cases with normal renal function.
There is no benefit to switching from an ACE inhibitor to an ARB. Nitrates have some effect on blood pressure but are recommended only for patients with coronary artery disease.
A 45-year-old male presents with a complaint of recent headaches. He has had four headaches this week, and his description indicates that they are moderate to severe, bilateral, frontal, and nonthrobbing. There is no associated aura. He has had similar episodes of recurring headachesin the past.
Based on this limited history, which one of the following headache types can be eliminated from the differential diagnosis?
A. Tension-type headache
B. Sinus headache
C. Migraine headache
D. Cluster headache
E. Headache of intracranial neoplasm
D
Cluster headache can be removed from the differential because it is always unilateral, although the affected side can vary. The remainder of these headache types can be bilateral, frontal, and nonthrobbing. Brain tumor headaches may be similar in character to previous headaches, but are often more severe or frequent.
In evaluating an adult with anemia, which one of the following findings most reliably indicates a diagnosis of iron deficiency anemia? (check one)
A. Low total iron-binding capacity
B. Low serum iron
C. Low serum ferritin
D. Microcytosis
E. Hypochromia
C
TIBC is elevated in IDA.
Serum Fe may be decreased in response to inflammation (secondary to hepcidin) even when total body stores of iron are not decreased.
Microcytosis and hypochromia are both features of IDA occurring late in its development, but both can also be seen in the thalassemias.
Serum ferritin is also an acute-phase reactant but is normal or elevated in the face of an inflammatory process. A low serum ferritin is diagnostic for iron deficiency even in its early stages.
A 24-year-old female presents with pelvic pain. She says that the pain is present on most days, but is worse during her menses. Ibuprofen has helped in the past but is no longer effective. Her menses are normal and she has only one sexual partner. A physical examination is normal. Which one of the following should be the next step in the workup of this patient? (check one)
A. Transvaginal ultrasonography
B. CT of the abdomen and pelvis
C. MRI of the pelvis
D. A CA-125 level
E. Colonoscopy
A
The initial evaluation for chronic pelvic pain should include a UA/UC, cervical swabs for G/C, CBC, ESR, β-hCG, and pelvic US.
CT and MRI are not part of the recommended initial diagnostic workup, but may be helpful in further assessing any abnormalities found on pelvic US.
Referral for diagnostic laparoscopy is appropriate if the initial workup does not reveal a source of the pain, or if endometriosis or adhesions are suspected.
Colonoscopy would be indicated if the history or examination suggests a GI source for the pain after the initial evaluation.
A 60-year-old male with a right-sided pleural effusion undergoes thoracentesis. Analysis of the pleural fluid reveals a protein level of 2.0 g/dL and an LDH level of 70 U/L. His serum protein level is 7.0 g/dL (N 6.0-8.3) and his serum LDH level is 200 U/L (N 100-105). Based on these findings, which one of the following is the most likely diagnosis? (check one)
A. Heart failure
B. Pulmonary embolism
C. Tuberculous pleurisy
D. Malignancy
E. Bacterial pneumonia
A
Lights criteria use ratios of fluid/serum values for protein and LDH. Pleural fluid/serum ratios greater than 0.6 for LDH and 0.5 for protein are indicative of exudates. In the scenario presented, both ratios are approximately 0.3; therefore, the fluid is a transudate. The list of causes for transudates is much shorter than for exudates. The vast majority of transudates are due to heart failure, with cirrhosis being the next most common cause. Once there is reasonable certainty that the fluid is a transudate, additional studies usually are not necessary. The other conditions listed result in exudative pleural effusions.
An 82-year-old female is hospitalized for pneumonia and sepsis. She has advance directives in place. Should it become necessary, the patient’s decision-making capacity is determined by:
A. The spouse or next of kin
B. The attending physician
C. A consulting psychiatrist
D. A judge, at the request of hospital social services or the physician
B
The attending physician is responsible for determining capacity and incapacity for decision making. The extent, cause, and probable duration of any incapacity should be documented in the clinical record.
The most appropriate advice for a 50-year-old female who has passed six calcium oxalate stones over the past 4 years is to: (check one)
A. restrict her calcium intake
B. restrict her intake of yellow vegetables
C. increase her sodium intake
D. increase her dietary protein intake
E. take potassium citrate with meals
E
Calcium oxalate stones are the most common of all renal calculi.
A low-sodium, restricted-protein diet with increased fluid intake reduces stone formation.
A low-calcium diet has been shown to be ineffective.
Oxalate restriction also reduces stone formation. Oxalate-containing foods include spinach, chocolate, tea, and nuts, but not yellow vegetables.
Potassium citrate should be taken at mealtime to increase urinary pH and urinary citrate
A 25-year-old white male who has a poorly controlled major seizure disorder and a 6-week history of recurrent fever, anorexia, and persistent, productive coughing visits your office. On physical examination he is noted to have a temperature of 38.3°C (101.0°F), a respiratory rate of 16/min, gingival hyperplasia, and a fetid odor to his breath. Auscultation of the lungs reveals rales in the mid-portion of the right lung posteriorly.
Which one of the following is most likely to be found on a chest radiograph? (check one)
A. Sarcoidosis
B. Miliary calcifications
C. A lung abscess
D. A right hilar mass
E. A right pleural effusion
C
Anaerobic lung abscesses are most often found in a person predisposed to aspiration who complains of a productive cough associated with fever, anorexia, and weakness. Physical examination usually reveals poor dental hygiene, a fetid odor to the breath and sputum, rales, and pulmonary findings consistent with consolidation.
Patients who have sarcoidosis usually do not have a productive cough and have bilateral physical findings. A persistent productive cough is not a striking finding in disseminated tuberculosis, which would be suggested by miliary calcifications on a chest film. The clinical presentation and physical findings are not consistent with a simple mass in the right hilum nor with a right pleural effusion.
A previously healthy 74-year-old male presents to the emergency department with a fever and altered mental status. His illness began 2 days ago with symptoms of fever, malaise, body aches, reduced appetite, nausea, and diarrhea. His temperature is 39.6°C (103.3°F) in the emergency department and his examination is nonfocal. Initial laboratory studies include a sodium level of 131 mEq/L (N 135–145) and a WBC count of 14,200/mm3 (N 4500–11,000) with a neutrophilic predominance. Blood and urine cultures are obtained and he is admitted to the hospital for observation. The next morning he develops a productive cough and shortness of breath. You order a chest radiograph, which shows patchy consolidation of the bilateral bases. Which one of the following is the most likely cause of this patient’s condition?
A. Chlamydophila pneumoniae
B. Legionella pneumophila
C. Mycoplasma pneumoniae
D. Streptococcus pneumoniae
B
Pneumonia caused by Legionella pneumophila is commonly preceded by nonspecific systemic symptoms that may lead a clinician to consider other diagnoses. Symptoms may include high-grade fever, malaise, myalgias, anorexia, and headache. Gastrointestinal and neurologic symptoms are also common and include nausea, vomiting, abdominal pain, diarrhea, and confusion. Focal neurologic signs are less common, but have been reported. Localizing respiratory symptoms will typically develop later, most often a dry cough and dyspnea. From this point on the illness resembles a typical pneumonia with fever, productive cough, pleuritic pain, and breathlessness.
A 53-year-old male presents to your office with a several-day history of hiccups. They are not severe, but have been interrupting his sleep, and he is becoming exasperated. What should be the primary focus of treatment in this individual?
A. Drug treatment to prevent recurrent episodes
B. Decreasing the intensity of the muscle contractions in the diaphragm
C. Finding the underlying pathology causing the hiccups
D. Improving the patient’s quality of sleep
E. Suppressing the current hiccup symptoms
C
Hiccups are caused by a respiratory reflex that originates from the phrenic and vagus nerves, as well as the thoracic sympathetic chain. Hiccups that last a matter of hours are usually benign and self-limited, and may be caused by gastric distention. Treatments usually focus on interrupting the reflex loop of the hiccup, and can include mechanical means (e.g., stimulating the pharynx with a tongue depressor) or medical treatment, although only chlorpromazine is FDA-approved for this indication.
If the hiccups have lasted more than a couple of days, and especially if they are waking the patient up at night, there may be an underlying pathology causing the hiccups. Identifying and treating the underlying disorder should be the focus of management for intractable hiccups.
An 83-year-old male has a long history of COPD. His resting oxygen saturation is 86% on room air. Treatment includes oral bronchodilators, inhaled corticosteroids, inhaled beta-agonists, inhaled cholinergics, and home oxygen. Which one of his treatments has been shown to prolong survival in cases such as this? (check one)
A. Oral bronchodilators
B. Inhaled corticosteroids
C. Inhaled beta-agonists
D. Inhaled cholinergics
E. Home oxygen
E
Treatment of hypoxemia is critical in the management of COPD and trials have shown a reduction in mortality with the use of oxygen for 15 or more hours daily.
Human parvovirus B19 is associated with which one of the following? (check one)
A. Erythema marginatum
B. Erythema multiforme
C. Erythema toxicum
D. Erythema infectiosum
E. Erythema chronicum
D
Parvovirus B19 is associated with erythema infectiosum, or fifth disease. It is also associated with nonspecific fever, arthropathy, chronic anemia, and transient aplastic crisis.
Contraindications to use of the levonorgestrel intrauterine system (Mirena) include which one of the following? (check one)
A. Nulliparity
B. A previous history of deep vein thrombosis
C. A previous history of endometriosis
D. Current pelvic inflammatory disease
E. Current breastfeeding
D
Contraindications to insertion of the levonorgestrel intrauterine system (LNG-IUS) include uterine anomalies, postpartum endometritis, untreated cervicitis, and current PID. Nulliparity may increase discomfort during insertion but is not a contraindication. Levonorgestrel is a synthetic progestin and is not associated with an increased risk of deep vein thrombosis. It also is not associated with any adverse effect on quantity or quality of milk in breastfeeding women, and has no adverse effects on the infant. The LNG-IUS is not contraindicated in patients with endometriosis, and there is some evidence that it may improve symptom scores in these women.
In an 11-year-old male with dark brown urine and hand and foot edema, which one of the following would be most suggestive of glomerulonephritis? (check one)
A. WBC casts in the urine
B. RBC casts in the urine
C. Eosinophils in the urine
D. Positive serum antinuclear antibody levels
E. Elevated C3 and C4 complement levels
B
Acute glomerulonephritis (AGN) in children manifests as brown/ cola-colored urine, which may be painless or associated with mild flank/abdominal pain. There are many etiologies of AGN but the most common in children are IgA nephropathy (which may directly follow an acute upper respiratory tract infection) and acute poststreptococcal glomerulonephritis following a streptococcal throat or skin infection (usually 7–21 days later).
In cases with more severe renal involvement, patients may develop HTN, edema, and oliguria. RBC casts are the classic finding on urinalysis in a patient with AGN. W
BC casts are seen in acute pyelonephritis, often manifested by high fever, and costovertebral angle or flank pain and tenderness. Patients may also appear septic. Positive serum antinuclear antibodies are associated with lupus nephritis. Urine eosinophils are seen in drug-induced tubulointerstitial nephritis. Serum complement levels are reduced, not elevated, in various forms of acute glomerulopathies, including poststreptococcal AGN.
A 32-year-old female who is an avid runner presents with knee pain. You suspect patellofemoral pain syndrome. Which one of the following signs or symptoms would prompt an evaluation for an alternative diagnosis? (check one)
A. Peripatellar pain while running
B. Knee stiffness with sitting
C. A popping sensation in the knee
D. Locking of the joint
E. A positive J sign (lateral tracking of the patella when moved from flexion to full extension)
D
Patellofemoral pain syndrome - characterized by anterior knee pain, particularly with activities that overload the joint, such as stair climbing, running, and squatting. Patients complain of popping, catching, stiffness, and giving way. On examination there will be a positive J sign, with the patella moving from a medial to a lateral location when the knee is fully extended from the 90° position. This is caused by an imbalance in the medial and lateral forces acting on the patella. Locking is not characteristic of patellofemoral pain syndrome, so a loose body or meniscal tear should be considered if this is reported.
A male infant is delivered at 41 weeks gestation by spontaneous vaginal delivery. The amniotic fluid is meconium stained. Apgar scores are 7 at 1 minute and 7 at 5 minutes. The baby is noted to have respiratory distress from birth and is hypoxic by pulse oximetry. Respiration improves with supplemental oxygen, as does the hypoxia, but does not return to normal. Which one of the following would most likely be seen on a chest radiograph? (check one)
A. A normal heart and lungs
B. Fluid in the pulmonary fissures
C. Homogeneous opaque infiltrates with air bronchograms
D. Patchy atelectasis
D
The CXR of a child with meconium aspiration syndrome will show patchy atelectasis or consolidation.
If the child has a normal chest film and respiratory distress, a noncardiopulmonary source should be considered (i.e., a neurologic or metabolic etiology).
The chest film of a child with transient tachypnea of the newborn will show a wet silhouette around the heart, diffuse parenchymal infiltrates, or intralobar fluid accumulation.
Homogeneous opaque infiltrates with air bronchograms on a CXR are seen with hyaline membrane disease.
Which one of the following medications has the best evidence for preventing hip fracture? (check one)
A. Ibandronate (Boniva)
B. Raloxifene (Evista)
C. Denosumab (Prolia)
D. Etidronate (Didronel)
E. Alendronate (Fosamax)
E
Ibandronate, raloxifene, denosumab, and etidronate have been shown to reduce new vertebral fractures, but are not proven to prevent hip fracture.
Only zoledronic acid, risedronate, and alendronate have been confirmed in sufficiently powered studies to prevent hip fracture, and these are the anti-osteoporosis drugs of choice.
A 5-year-old male is scheduled for elective hernia repair at 11:00 a.m. Which one of the following would be the most appropriate recommendation? (check one)
A. No solid food for 8 hours prior to surgery and clear liquids until 2 hours prior to surgery
B. No solid food 4 hours prior to surgery and clear liquids until 2 hours prior to surgery
C. No solid food after midnight and nothing by mouth 8 hours prior to surgery
D. Nothing by mouth 2 hours prior to surgery
E. Nothing by mouth 8 hours prior to surgery
A
Recent American Society of Anesthesiologists guidelines recommend the following restrictions on diet prior to surgery for pediatric patients: 8 hours for solid food, 6 hours for formula, 4 hours for breast milk, and 2 hours for clear liquids. These changes have resulted in decreased numbers of canceled cases and pediatric patients who are less irritable preoperatively and less dehydrated at the time of anesthesia induction.
Which one of the following is a criterion for gastric bypass surgery, according to recommendations of the National Institutes of Health? (check one)
A. A Framingham risk score >25%
B. Severe insulin resistance
C. Failed pharmacotherapy
D. Clearance by a mental health professional
E. A BMI >30 kg/m2 with comorbidities
D
Indications for laparoscopic bariatric surgery include a BMI >40 kg/m2 or a BMI of 35-40 kg/m2 with significant obesity-related comorbidities.
Weight loss by nonoperative means should be attempted before surgery, and patients should be evaluated by a multidisciplinary team that includes a dietician and a mental health professional before surgery.
A 32-year-old primipara is ready to be discharged after a full-term vaginal delivery that was complicated by a prolonged second stage of labor. She required a second-degree posterior vaginal repair, but had no periurethral trauma. A transurethral catheter was removed a few hours after delivery, but 48 hours later she complained of abdominal pain and a persistent need to urinate. The catheter was replaced and yielded approximately 2000 cc of straw-colored urine. Urinary symptoms quickly resolved, but the patient continues to be unable to void on her own. A perineal examination is normal, as is a urinalysis.
Which one of the following would be the most appropriate management at this time?
(check one)
A. Oxybutynin (Ditropan), 10 mg daily
B. Prednisone, starting with 60 mg/day and tapering quickly over 7 days
C. Urgent vaginal ultrasonography
D. Urology consultation for cystoscopy
E. Discharge with a catheter in place and close follow-up
E
Postpartum urinary retention (PUR) - defined as a post-void bladder residual of at least 150 cc present 6 hours or more after delivery. This condition is more likely to occur in patients who are primiparous, have a prolonged first or second stage of labor, have instrumented vaginal deliveries, or require a cesarean section for failure to progress.
Most cases will resolve 2–6 days after delivery, but some can take up to several weeks. The use of intermittent self-catheterization or a transurethral catheter is recommended until the patient’s ability to spontaneously micturate returns.
A 72-year-old Hispanic female with moderately severe Alzheimer’s disease is hospitalized for treatment of a fracture of the left humerus. The first night after admission she becomes confused and agitated.
The most appropriate management at this point is which one of the following?
(check one)
A. Physical restraints
B. Benzodiazepines for agitation
C. Meperidol (Demerol) for pain control
D. Moving the patient to the intensive-care unit for better monitoring
E. Having a bedsitter or family member stay in the room to reassure and orient the patient
E
Delirium is a frequent complication of hospital admission in older patients, especially those with preexisting dementia. Orientation and reassurance in a quiet environment will usually be effective in treating the confusion and agitation, once serious causes of the delirium have been ruled out.
Benzodiazepines and meperidol have been reported to cause delirium.
Physical restraints and restrictive environments (e.g., intensive-care units) can predispose to delirium and are best avoided if possible.
A 48-year-old female with type 2 diabetes has been hospitalized for 4 days with persistent fever. Her diabetes has been controlled with diet and glyburide (Micronase, DiaBeta). You saw her 2 weeks ago in the office with urinary frequency, urgency, and dysuria. At that time a urinalysis showed 25 WBCs/hpf, and a urine culture subsequently grew Escherichia colisensitive to all antibiotics. She was placed on trimethoprim/sulfamethoxazole (Bactrim, Septra) empirically. She improved over the next week, but then developed flank pain, fever to 39.5°C (103.1°F), and nausea and vomiting. She was hospitalized and intravenous cefazolin (Kefzol) and gentamicin were started while blood and urine cultures were performed. This urine culture also grew E. coli sensitive to the current antibiotics. Her temperature has continued to spike to 39.5°C since admission, without any change in her symptoms.
Which one of the following would be most appropriate at this time? (check one)
A. Add vancomycin (Vancocin) to the regimen
B. Order a radionuclide renal scan
C. Order intravenous pyelography
D. Order a urine culture for tuberculosis
E. Order CT of the abdomen
E
Perinephric abscess - collection of pus in the tissue surrounding the kidney, generally in the space enclosed by Gerota’s fascia. Clinical features may be quite variable, and the most useful predictive factor in distinguishing uncomplicated pyelonephritis from perinephric abscess is persistence of fever for more than 4 days after initiation of antibiotic therapy. The radiologic study of choice is CT, as this can detect perirenal fluid, enlargement of the psoas muscle (both are highly suggestive of the diagnosis), and perirenal gas (which is diagnostic).
Most perinephric infections occur as an extension of an ascending urinary tract infection, commonly in association with renal calculi or urinary tract obstruction. Patients with anatomic urinary tract abnormalities or diabetes mellitus have an increased risk.
A 35-year-old male with a previous history of kidney stones presents with symptoms consistent with a recurrence of this problem. The initial workup reveals elevated serum calcium. Which one of the following tests would be most appropriate at this point? (check one)
A. Serum calcitonin
B. 24-hour urine for calcium and phosphate
C. Serum phosphate and magnesium
D. Serum parathyroid hormone
E. Spot urine for microalbumin
D
A patient with a recurrent kidney stone and an elevated serum calcium level most likely has hyperparathyroidism, and a parathyroid hormone (PTH) level would be appropriate.
Elevated PTH is caused by a single parathyroid adenoma in approximately 80% of cases. The resultant hypercalcemia is often discovered in asymptomatic persons having laboratory work for other reasons. An elevated PTH by immunoassay confirms the diagnosis.
A postmenopausal female who has recently been diagnosed with hypertension returns for follow-up 3 months after the initiation of therapeutic lifestyle changes. Her blood pressure has improved but remains higher than goal at 142/90 mm Hg, and pharmacologic treatment is indicated. The patient has a family history of osteoporosis.
Which one of the following may slow the demineralization of bone in this patient?
A. An ACE inhibitor
B. An α-blocker
C. A β-blocker
D. A calcium channel blocke
E. A thiazide diuretic
E
An adult patient with a confirmed SBP >139 mm Hg or DBP >89 mm Hg is hypertensive. JNC-7 guidelines recommend the adoption of healthy lifestyles for all patients, especially those with HTN, and the addition of pharmacologic treatment as necessary to reach a goal BP
A 27 yo white M presents 2 hours after being bitten by a rattlesnake. He complains of weakness, abdominal cramping, left leg pain and swelling. His speech is slurred, and his breath smells of alcohol. PE: 37.0° C (98.6° F) BP 100/60 mm Hg P 122 beats/min RR 24/min Skin diaphoretic; ecchymoses on both forearms; bite puncture site just above left lateral malleolus Lungs clear, Cardiac exam normal heart tones, 1+ posterior tibial pulses Abdomen flat; hypoactive bowel sounds; no masses or guarding Extremities visible swelling of left leg and thigh; skin tightness of left leg Neurologic decreased sensation to light touch and sharp sensation in left foot Which one of the following therapeutic interventions is indicated? (check one)
A. Antivenin administration
B. Venom extractor use
C. Tourniquet application at the upper thigh
D. Surgical consultation for decompression fasciotomy
E. Administration of platelets and fresh frozen plasma
A
This patient presents with a history of snakebite, swelling of an entire extremity, weakness, and ecchymosis. This is consistent with a grade III envenomation and merits antivenin therapy. Antivenin is indicated before any consideration of compartment syndrome. Pressure measurements would be required because of the clinical similarities between envenomation injury and compartment syndrome.
A 3-week-old infant is brought to your office with a fever. He has a rectal temperature of 38.3°C (101.0°F), but does not appear toxic. The remainder of the examination is within normal limits. Which one of the following would be the most appropriate management for this patient? (check one)
A. Admit to the hospital; obtain urine, blood, and CSF cultures; and start intravenous antibiotics
B. Admit to the hospital and treat for herpes simplex virus infection
C. Follow up in the office in 24 hours and admit to the hospital if not improved
D. Order a CBC and urinalysis with urine culture, and send the patient home if the results are normal
A
Any child younger than 29 days old with a fever or any child who appears toxic, regardless of age, should undergo a complete sepsis workup and be admitted to the hospital for observation until culture results are known or the source of the fever is found and treated.
Observation only, with close follow-up, is recommended for nontoxic infants 3 - 36 months of age with a temperature
Children 29-90 days old who appear to be nontoxic and have negative screening laboratory studies, including a CBC and UA, can be sent home with precautions and with follow-up in 24 hours.
Testing for neonatal herpes simplex virus infection should be considered in patients with risk factors, including maternal infection at the time of delivery, use of fetal scalp electrodes, vaginal delivery, cerebrospinal fluid pleocytosis, or herpetic lesions. Testing also should be considered when a child does not respond to antibiotics
A previously healthy 27-year-old female presents with dysuria and urinary urgency and frequency. She also complains of right flank pain, fevers and chills, and N without V. She has a decreased appetite, but has been able to drink liquids.
T 38.4°C (101.2°F), HR 102 beats/min, BP 126/82 mm Hg. She has mild suprapubic tenderness and right CVA tenderness. UA shows microscopic pyuria, hematuria, and a positive leukocyte esterase test. CBC - leukocytosis with a left shift, negative pregnancy test. The patient does not have allergies to any antibiotics.
Which one of the following would be most appropriate for this patient?
A. Outpatient management with oral amoxicillin
B. Outpatient management with oral ciprofloxacin (Cipro)
C. Outpatient management with oral nitrofurantoin (Macrodantin)
D. Inpatient management with intravenous ceftriaxone (Rocephin)
E. Inpatient management with intravenous levofloxacin (Levaquin)
B
Nitrofurantoin for 5 days is an appropriate treatment for an uncomplicated UTI, but not for pyelonephritis. Fluoroquinolones, such as ciprofloxacin, are the preferred empiric antibiotic treatment for outpatient treatment of pyelonephritis, as long as the local prevalence of resistance to community-acquired Escherichia coli is ≤10%.
Amoxicillin is generally not considered first-line treatment for pyelonephritis because of a high prevalence of resistance to oral β-lactam antibiotics, and it should only be chosen if susceptibility results for the urinary isolate are known and indicate likely activity.
Which one of the following is the greatest risk factor for abdominal aortic aneurysm (AAA)? (check one)
A. Cigarette smoking
B. Diabetes mellitus
C. Hypertension
D. African-American race
E. Female gender
A
Which one of the following is most likely to induce withdrawal symptoms if discontinued abruptly? (check one)
A. Venlafaxine (Effexor)
B. Divalproex (Depakote)
C. Fluoxetine (Prozac)
D. Olanzapine (Zyprexa)
E. Donepezil (Aricept)
A
The abrupt discontinuation of venlafaxine, or a reduction in dosage, is associated with withdrawal symptoms much more severe than those seen with other SSRIs. These symptoms include agitation, anorexia, confusion, impaired coordination, seizures, sweating, tremor, and vomiting. To avoid this withdrawal symptom, dosage changes should be instituted gradually.
Abrupt discontinuation of mood stabilizers such as divalproex, and atypical antipsychotics such as olanzapine, can result in the return of psychiatric symptoms, but not severe physiologic dysfunction. Similarly, stopping anticholinesterase inhibitors such as donepezil will not cause a withdrawal syndrome.
A 50-year-old male with a history of methamphetamine abuse requests medication to treat this problem. According to evidence-based studies, which one of the following would be most likely to help this patient overcome methamphetamine dependence? (check one)
A. Fluoxetine (Prozac)
B. Amlodipine (Norvasc)
C. Imipramine
D. Bupropion (Wellbutrin)
E. Cognitive therapy
E
Methamphetamine dependence is very difficult to treat. No medications have been approved by the FDA for the treatment of this problem, nor have any studies shown consistent benefit to date. The standard therapy for methamphetamine dependence is outpatient behavioral therapies, especially with case management included. Therapy must be individualized. Support groups and 12-step drug-treatment programs may be helpful
Which one of the following is an absolute contraindication to electroconvulsive therapy (ECT)? (check one)
A. Age >80 years
B. A cardiac pacemaker
C. An implantable cardioverter-defibrillator
D. Pregnancy
E. There are no absolute contraindications to ECT
E
ECT can be used safely in elderly patients and in persons with cardiac pacemakers or implantable cardioverter-defibrillators. ECT also can be used safely during pregnancy, with proper precautions and in consultation with an obstetrician.
There are no absolute contraindications to electroconvulsive therapy (ECT), but persons who may be at increased risk for complications include those with unstable cardiac disease such as ischemia or arrhythmias, cerebrovascular disease such as recent cerebral hemorrhage or stroke, or increased intracranial pressure
A 75-year-old male develops a mild Clostridium difficile infection and is treated with 10 days of metronidazole (Flagyl), 500 mg orally 3 times daily. The diarrhea recurs 10 days after he completes the course of treatment.
Which one of the following would be most appropriate? (check one)
A. Repeat the course of metronidazole
B. Repeat the course of metronidazole and add vancomycin
C. Administer vancomycin intravenously
D. Prescribe loperamide (Imodium), 4 mg twice daily as needed
E. Prescribe a probiotic
A
Clostridium difficile infection is more common with aging and can be treated with either metronidazole or vancomycin daily. For mild recurrent disease, repeating the course of the original agent is appropriate.
Multiple recurrences or severe disease warrants the use of both agents.
A 44-year-old female with localized breast cancer is receiving counseling about adjuvant long-term therapy. Which one of the following is more likely to occur with an aromatase inhibitor such as letrozole (Femara) than with tamoxifen (Soltamox)?
A. Endometrial cancer
B. Venous thromboembolism
C. Inflammatory arthritis
D. Myalgias
D
Myalgias and noninflammatory arthralgias are more likely with aromatase inhibitors.
Endometrial cancer may occur with long-term use of tamoxifen.
For the prevention of ischemic stroke in patients at low risk for gastrointestinal bleeding, the
U.S. Preventive Services Task Force recommends aspirin for? (check one)
A. Men age 45–79
B. Men age 55–79
C. Women age 45–79
D. Women age 55–79
E. No one, regardless of sex or age
C
The U.S. Preventive Services Task Force has concluded that the net benefit of daily aspirin is substantial in women 55–79 years of age for whom the benefit of ischemic stroke prevention exceeds the harm of an increased risk for gastrointestinal bleeding.
Aspirin use is recommended in men 45–79 years of age for prevention of myocardial infarction when the potential benefit outweighs the potential harm of gastrointestinal hemorrhage.
Net benefit of aspirin
W 55-79 Stroke
M 45-79 MI
Which one of the following is the most effective drug for the treatment of alcohol dependence? (check one)
A. Disulfiram (Antabuse)
B. Diazepam (Valium)
C. Amitriptyline (Elavil)
D. Fluoxetine (Prozac)
E. Naltrexone (ReVia)
E
Of the several drugs studied for the treatment of dependence, the evidence of efficacy is strongest for naltrexone (opioid antagonist) and acamprosate (NMDA antagonist and GABA analog)
You are asked to see a mentally challenged 45-year-old male from a nearby group home who has groin pain. On examination you notice that he has large ears, a prominent jaw, and large symmetric testicles. These findings are consistent with:
A. a variant form of Down syndrome
B. Asperger’s syndrome
C. Klinefelter’s syndrome
D. homocystinuria
E. Fragile X syndrome
E
Fragile X syndrome accounts for more cases of mental retardation in males than any other genetic disorder except Down syndrome; about one in 4000–6000 males is affected. Down syndrome, Klinefelter’s syndrome, and homocystinuria do not present with the described findings. Asperger’s syndrome is a variant of autism in people of normal to high intelligence. Patients with Klinefelter’s syndrome usually have small testicles.
A 24-year-old primigravida has nausea and vomiting associated with pregnancy. Which one of the following is recommended by the American Congress of Obstetricians and Gynecologists (ACOG) as first-line therapy? (check one)
A. Droperidol (Inapsine)
B. Ondansetron (Zofran)
C. Prochlorperazine
D. Metoclopramide (Reglan)
E. Doxylamine (Unisom) and vitamin B6
E
Doxylamine (Unisom) and vitamin B6 is associated with a 70% reduction in N/V, with no evidence of teratogenicity.
A 63-year-old white male has been diagnosed with myasthenia gravis and is experiencing progressive muscle weakness despite maximum pharmacotherapy. Which one of the following surgical options would be most likely to improve his condition? (check one)
A. Thyroidectomy
B. Radioactive thyroid ablation
C. Adrenalectomy
D. Removal of a pituitary microadenoma
E. Thymectomy
E
Myasthenia gravis is a neuromuscular illness with an underlying immune-related cause. Corticosteroids and anticholinesterase medications such as oral pyridostigmine can be helpful, but thymectomy may be appropriate for patients with generalized disease not responding to medication. Thymectomy increases the remission rate and improves the clinical course.
A 42-year-old male sees you for help to quit smoking. His sister had excellent results with bupropion (Zyban) and he asks if he could try using it. When you review his medical history, which one of the following would be a contraindication to bupropion?
(check one)
A. Diabetes mellitus
B. Gout
C. Hypertension
D. Hyperthyroidism
E. A seizure disorder
E
Bupropion can lower the seizure threshold and should not be used in patients who have a history of a seizure disorder or who drink heavily. A history of the other medical conditions listed does not contraindicate the use of bupropion.
A 68-year-old African-American male with a history of hypertension and heart failure continues to have shortness of breath and fatigue after walking only one block. He has normal breath sounds, no murmur, and no edema on examination. His current medications include furosemide (Lasix), 20 mg/day, and metoprolol extended-release (Toprol-XL), 50 mg/day. He previously took lisinopril (Prinivil, Zestril), but it was discontinued because of angioedema. A recent echocardiogram showed an ejection fraction of 35%.
Which one of the following would be most likely to improve both symptoms and survival in this patient?
A. Valsartan (Diovan)
B. Metolazone (Zaroxolyn)
C. Digoxin
D. Verapamil (Calan, Isoptin)
E. Isosorbide/hydralazine (BiDil)
e
In patients with systolic heart failure, the usual management includes an ACE inhibitor and a ß-blocker. Since this patient had angioedema with an ACE inhibitor, an angiotensin receptor blocker may cause this side effect as well. Adding metolazone is generally not necessary unless the patient has volume overload that does not respond to increased doses of furosemide. Digoxin may improve symptoms, but has not been shown to increase survival.
For patients who cannot tolerate an ACE inhibitor, especially African-Americans, a combination of direct-acting vasodilators such as isorbide and hydralazine is preferred.
Verapamil has a negative inotropic effect and should not be used.
A chest radiograph of the driver of an automobile involved in a head-on collision shows a widened mediastinum. This suggests: (check one)
A. myocardial contusion
B. spontaneous rupture of the esophagus
C. rupture of a bronchus
D. partial rupture of the thoracic aorta
E. acute heart failure
D
Deceleration-type blows to the chest can produce partial or complete transection of the aorta. A CXR shows an acutely widened mediastinum and/or a pleural effusion when the condition is severe.
The other conditions listed would produce mediastinal emphysema (esophageal or bronchial rupture), a widened heart, or pulmonary edema (acute heart failure, myocardial contusion).
Cow’s milk should be withheld from a child’s diet until what age? (check one)
A. 4 months
B. 6 months
C. 9 months
D. 12 months
E. 15 months
D
Whole cow’s milk does not supply enough vitamin E, iron, and essential FA, and overburdens their system with too much protein, Na, and K.
Skim and low-fat milk lead to the same problems as whole milk, and also fail to provide adequate calories for growth.
For these reasons cow’s milk is not recommended for children under 12 months of age.
Human breast milk or iron-fortified formula, with introduction of solid foods after 4-6 months of age if desired, is appropriate for the first year of life.
A 42-year-old male with a history of chronic hepatitis C develops left leg cellulitis and is treated with cephalexin (Keflex). He returns to your office 5 days later for follow-up, and the cellulitis is responding favorably to treatment. However, the patient has a generalized maculopapular rash and a low-grade fever, which he says began 3 days ago. He also complains of arthralgias. You admit him to the hospital for further evaluation.
His serum creatinine level is 3.2 mg/dL (N 0.6–1.5), which is elevated from his baseline level of 0.8 mg/dL. A urinalysis is normal, except for the presence of occasional eosinophils. The remainder of his evaluation, including liver enzyme levels and renal US, is normal. Which one of the following is the most appropriate next step in the management of this patient?
A. A postvoid residual urine volume
B. A hepatitis C viral load and genotype
C. Discontinuing cephalexin
D. Antibiotics to cover methicillin-resistant Staphylococcus aureus (MRSA)
E. Aggressive fluid resuscitation with normal saline
C
AKI is currently defined as either a rise in serum Cr or a reduction in urine output. Cr must increase by at least 0.3 mg/dL, or to 50% above baseline within a 24-48 hour period. A reduction in urine output to 0.5 mL/kg/hr for longer than 6 hours also meets the criteria.
Acute interstitial nephritis is an intrinsic renal cause of AKI. These patients are often nonoliguric. A history of recent medication use is key to the diagnosis, as cephalosporins and penicillin analogues are the most common causes. Approximately one-third of patients present with a maculopapular rash, fever, and arthralgias. Eosinophilia and sterile pyuria may also be seen in addition to eosinophiluria. Discontinuation of the offending drug is the cornerstone of management.
An otherwise healthy 1-year-old white male has a screening hemoglobin level of 10.5 g/dL (N 11.3–14.1), a mean corpuscular volume of 68 fL (N 71–84), and an undetectable serum lead level. What should be your next step? (check one)
A. A therapeutic trial of iron for 1 month
B. A serum ferritin level
C. An erythrocyte protoporphyrin level
D. Hemoglobin electrophoresis
E. Bone marrow examination
A
It is important to screen for anemia during late infancy. Iron deficiency is the most common cause of anemia in this age group. There is evidence that persistent iron deficiency in childhood may have a negative impact on cognitive development. A therapeutic trial of iron is the best approach to the treatment of iron deficiency in late infancy. If the anemia fails to respond, investigating other causes of anemia is indicated
An 82-year-old male nursing-home resident is sent to the emergency department with lower abdominal pain and bloody diarrhea. He has a history of multi-infarct dementia, hypertension, and hyperlipidemia. On examination he is afebrile, and a nasogastric aspirate is negative for evidence of bleeding.
Which one of the following is the most likely cause of this patient’s bleeding?
A. Peptic ulcer disease
B. Ischemic colitis
C. Diverticular bleeding
D. Angiodysplasia
E. Infectious colitis
B
This patient most likely has ischemic colitis, given the abdominal pain, bloody diarrhea, and cardiovascular risks. Peptic ulcer disease is unlikely because the nasogastric aspirate was negative. Diverticular bleeding and angiodysplasia are painless. Infectious colitis is associated with fever.
Because of safety concerns, which one of the following asthma medications should be used only as additive therapy and not as monotherapy? (check one)
A. Inhaled corticosteroids
B. Leukotriene-receptor antagonists
C. Short-acting β2-agonists
D. Long-acting β2-agonists
E. Mast cell stabilizers
D
Because of the risk of asthma exacerbation or asthma-related death, the FDA has added a warning against long-acting β2-agonists as monotherapy.
Inhaled corticosteroids, leukotriene-receptor antagonists, short-acting β2-agonists, and mast-cell stabilizers are approved and accepted for both monotherapy and combination therapy in the management of asthma.
Of the following, which one is the most effective treatment for bulimia nervosa? (check one)
A. Fluoxetine (Prozac)
B. Buspirone (BuSpar)
C. Prochlorperazine (Compazine)
D. Omeprazole (Prilosec)
E. Metoclopramide (Reglan)
A
Fluoxetine has FDA approval for this indication.
A 19-year-old college student comes to your office with her mother. The mother reports that her daughter has frequently been observed engaging in binge eating followed by induced vomiting. She has also admitted to using laxatives to prevent weight gain.Which one of the following laboratory abnormalities is most likely to be found in this patient? (check one)
A. Hypokalemia
B. Hypoglycemia
C. Hyponatremia
D. Hypercalcemia
E. Hypermagnesemia
A
The patient described is likely suffering from bulimia. These patients use vomiting, laxatives, or diuretics to prevent weight gain after binge eating. This often causes a loss of potassium, leading to weakness, cardiac arrhythmias, and respiratory difficulty. The levels of other electrolytes are not as dramatically affected.
A 2-year-old white female is brought to your office by her parents, who are concerned about the child’s “flat feet.” On evaluation, the child’s feet are flat with weight-bearing, but with toe standing and with sitting the arch appears. You would: (check one)
A. Reassure the parents
B. Recommend orthotics
C. Recommend surgery
D. Recommend casting
E. Recommend foot-stretching exercises
A
Flexible flat feet as described are not pathologic unless painful, which is uncommon. Flexibility of the flat foot is determined by appearance of an arch when the feet are not bearing weight. No treatment is indicated for painless flexible flatfoot. Spontaneous correction is usually expected within 1 year of walking.
An 18-year-old white female presents with small, localized warts on the vulva and lower vaginal mucosa. She wants to avoid injections and surgical treatment if possible. Which one of the following is an acceptable topical agent for treating these vaginal lesions? (check one)
A. Trichloroacetic acid
B. Podofilox gel (Condylox)
C. Imiquimod cream (Aldara)
D. Interferon
E. Podophyllin 25% solution in alcohol (Podocon-25, Podofin)
A
TCA is acceptable for use on vaginal mucosa and is also acceptable for use when pregnancy is a possibility.
Podofilox and podophyllin in alcohol are not safe for use on mucosa.
Imiquimod cream is also not approved for mucosal use.
Interferon requires injection.
You examine an 11-month-old male who has had several paroxysms of abdominal pain in the last 2 hours. The episodes last 1–2 minutes; the infant screams, turns pale, and doubles up. Afterward, he seems normal. A physical examination is normal except for a possible fullness in the right upper quadrant of the abdomen.
The most likely diagnosis is: (check one)
A. pyloric stenosis
B. choledochal cyst
C. Meckel’s diverticulum
D. intussusception
E. intestinal malrotation
D
This is a classic presentation for intussusception, which usually occurs in children under the age of 2 years and is characterized by paroxysms of colicky abdominal pain. A mass is palpable in about two-thirds of patients.
Pyloric stenosis presents with a palpable mass, but usually develops between 4 and 6 weeks of age.
A choledochal cyst presents with the classic triad of RUQ pain, jaundice, and a palpable mass. Meckel’s diverticulum usually presents in this age group with painless lower gastrointestinal bleeding. Intestinal malrotation usually presents within the first 4 weeks of life and is characterized by bilious vomiting.
At the 18-month visit, which one of the following is the most specific sign of autism? (check one)
A. Delayed or odd use of language
B. Repetitive behaviors
C. Stereotypic movements
D. Delayed attainment of social skill milestones
E. Self-injurious behaviors
D
Delayed attainment of social skill milestones is the earliest and most specific sign of autism. Delayed or odd use of language is a common, but less specific, early sign of autism. Compared with social and language impairments, restricted interests and repetitive behaviors are less prominent and more variable in young children. Self-injurious behaviors are associated with autism, but not specific for it. For example, new-onset head banging may be the way an autistic child attempts to deal with pain from a dental abscess, headache, sinusitis, otitis media, or other source of pain.
Which one of the following is more likely to occur with glipizide (Glucotrol) than with metformin (Glucophage)? (check one)
A. Lactic acidosis
B. Hypoglycemia
C. Weight loss
D. Gastrointestinal distress
B
Metformin is a biguanide; main advantages other oral anti-diabetic agents is that it does not cause hypoglycemia. Lactic acidosis, while rare, can occur in patients with renal impairment.
In contrast to most other agents for the control of elevated glucose, which often cause weight gain, metformin reduces insulin levels and more frequently has a weight-neutral or even a weight loss effect.
Gastrointestinal distress is a common side-effect of metformin, particularly early in therapy.
A 30-year-old African-American female presents with a vaginal discharge. On examination the discharge is homogeneous with a pH of 5.5, a positive whiff test, and many clue cells. Which one of the following findings in this patient is most sensitive for the diagnosis of bacterial vaginosis? (check one)
A. The pH of the discharge
B. The presence of clue cells
C. The character of the discharge
D. The whiff test
A
Patients must have 3 of 4 Amsel criteria to be diagnosed with bacterial vaginosis. These include
- pH >4.5 (most sensitive)
- clue cells >20% (most specific)
- homogeneous discharge
- positive whiff test (amine odor with addition of KOH)
A 29-year-old white female is hospitalized following a right middle cerebral artery stroke confirmed by MRI. Her past medical history is remarkable only for a history of an uncomplicated tonsillectomy during childhood and a second-trimester miscarriage 3 years ago. The only remarkable finding on physical examination is left hemiplegia.The initial laboratory workup reveals normal hematocrit and hemoglobin levels, a normal prothrombin time, and a platelet count of 200,000/mm3 (N 140,000–440,000). The activated partial thromboplastin time is 95 sec (N 23.6–34.6), and it does not normalize when the patient’s serum is mixed with normal plasma. A serum VDRL is positive, and a serum FTA-ABS is nonreactive.
Which one of the following is the most likely diagnosis?
A. Hemophilia
B. Neurosyphilis
C. Antiphospholipid syndrome
D. Thrombotic thrombocytopenic purpura
E. Protein C deficiency
C
Antiphospholipid syndrome is due to the presence of lupus anticoagulant and anticardiolipin antibodies, which bind to negatively charged phospholipids. The antibodies are usually detected by a false-positive serologic test for syphilis.
Clinical features include venous + arterial thrombosis, fetal wastage, thrombocytopenia, and the presence of an activated partial thromboplastin time (aPTT) inhibitor. It is an important diagnostic consideration in all patients with unexplained thrombosis or cerebral infarction, particularly in young patients.
Although hemophilia would also be associated with a prolonged aPTT, the PTT would normalize when the patient’s serum was mixed with normal plasma. Neurosyphilis is excluded by the negative serum FTAABS result. Thrombotic thrombocytopenic purpura is not associated with prolongation of the aPTT and is associated with a hemolytic anemia. Although protein C deficiency is a hypercoagulable state that can lead to stroke, none of the laboratory abnormalities suggests this diagnosis.
A 50-year-old male has a pre-employment chest radiograph showing a pulmonary nodule. There are no previous studies available. Which one of the following would raise the most suspicion that this is a malignant lesion if found on the radiograph? .
A. The absence of calcification
B. Location above the midline of the lung
C. A diameter of 4 mm
D. A solid appearance
A
features of benign nodules: diameter
- think of benign as s’s: 5, smooth, solid, concentric calcifications, slow
Features of malignant nodules: diameter >10 mm, an irregular border, a “ground glass” appearance, either no calcification or an eccentric calcification, and a doubling time of 1 month to 1 year
The most common initial symptom of Hodgkin lymphoma is: (check one)
A. unexplained fever
B. night sweats
C. weight loss
D. painless lymphadenopathy
E. cough
D
The most common presenting symptom of Hodgkin lymphoma is painless lymphadenopathy.
Approximately one-third of patients with Hodgkin lymphoma present with unexplained fever, night sweats, and recent weight loss, collectively known as “B symptoms.”
Other common symptoms include cough, chest pain, dyspnea, and superior vena cava obstruction caused by adenopathy in the chest and mediastinum.
A 40-year-old white male was seen 4 weeks ago for a sudden onset of cough and shortness of breath. At that visit his O2 saturation was 92%, but his examination and a chest radiograph were normal. You prescribed azithromycin (Zithromax) and an albuterol inhaler (Proventil, Ventolin). Ten days later he was feeling well and his oxygen saturation was 97%. Today he returns to the office with a dry cough and shortness of breath.
On examination he has rare inspiratory rales that clear with deep breaths, and he has an O2 saturation of 86%. A chest film and a D-dimer test are normal. Pulmonary function tests show significant restriction that improves only minimally with albuterol. He has not been exposed to anyone with a similar illness, has no history of asthma, and has no smoking history or occupational exposure. However, he reports that 2 months ago his home was flooded after a heavy rain, and he has been tearing out carpeting that was ruined by the flood. Which one of the following is the most likely diagnosis?
A. Persistent asthma with acute exacerbations
B. Legionnaires’ disease
C. Pulmonary embolism
D. Hypersensitivity pneumonitis
D
Hypersensitivity pneumonitis can present in acute, subacute, or chronic forms.
- Acute hypersensitivity pneumonitis - symptoms resolve over several days, but will suddenly and violently recur with repeated exposure to the offending antigen.
- Subacute - begins gradually over weeks or months, causing a cough and increasing SOB.
- Chronic - develops over years of exposure, causing fibrotic changes to the lungs that will be evident on radiographs, as well as chronic crackles on auscultation.
The case described includes two episodes of the acute form. The patient was exposed to mold antigens in his flooded home. Within 4-8 hours of exposure, chills, cough, and shortness of breath will be noted, and at times will be dramatic. A chest film can be normal, even with significant hypoxia. PFTs show restrictive changes, compared obstructive changes in acute asthma. Blood tests often show an elevated erythrocyte sedimentation rate. Serum IgG tests for the probable antigen confirm the diagnosis.
Asthma would be an unlikely diagnosis in this case, with the pulmonary function tests showing restrictive changes rather than obstructive changes, and little improvement with albuterol. Also, the lack of a previous history of asthma makes it less likely. Legionnaires’ disease is always possible, but is unlikely in this case given the sudden onset, quick recovery over several days, and sudden recurrence. Pulmonary embolism is ruled out by the negative D-dimer test.
Which one of the following is the preferred treatment for patients with obsessive-compulsive disorder? (check one)
A. Lithium carbonate
B. Alprazolam (Xanax)
C. Fluoxetine (Prozac)
D. Amitriptyline (Elavil)
E. Valproic acid (Depakene)
C
SSRIs such as fluoxetine and fluvoxamine are FDA-approved and considered first-line agents in the treatment of OCD
Which one of the following is associated with ulcerative colitis rather than Crohn’s disease? (check one)
A. The absence of rectal involvement
B. Transmural involvement of the colon
C. Segmental noncontinuous distribution of inflammation
D. Fistula formation
E. An increased risk of carcinoma of the colon
E
Long-standing ulcerative colitis (UC) is associated with an increased risk of colon cancer. The greater the duration and anatomic extent of involvement, the greater the risk. Initial colonoscopy for patients with pancolitis of 8-10 years duration (regardless of the patient’s age) should be followed up with surveillance examinations every 1-2 years, even if the disease is in remission.
All of the other options listed are features typically associated with Crohn’s disease. Virtually all patients with UC have rectal involvement, even if that is the only area affected. In Crohn’s disease, rectal involvement is variable. Noncontinuous and transmural inflammation are also more common with Crohn’s disease. Transmural inflammation can lead to eventual fistula formation, which is not seen in UC.
In addition to calcium and vitamin D supplementation, patients who are beginning long-term treatment with prednisone (≥3 months at a dosage ≥5 mg/day) should also receive (check one)
A. bisphosphonate therapy
B. calcitonin
C. estrogen replacement therapy
D. recombinant human parathyroid hormone
E. raloxifene (Evista)
A
The American College of Rheumatology recommends that patients who are beginning long-term treatment with prednisone (≥3 months at a dosage ≥5 mg/day), or an equivalent, receive bisphosphonates in addition to calcium and vitamin D supplementation, regardless of their DEXA-scan T score. The other treatments are not recommended for prevention of glucocorticoid-induced osteoporosis.
The Timed Up and Go test consists of a patient rising from a chair, walking 3 meters (or about 10 feet), turning around, walking back, and sitting back down. The average healthy adult over the age of 60 can perform this in how many seconds? (check one)
A. 5
B. 10
C. 20
D. 30
E. 45
B
For the average adult over the age of 60, the normal time required for the Timed Up and Go test is 10 seconds. A time longer than 10 seconds may indicate weakness, a balance or gait problem, and/or an increased fall risk.
Which one of the following side effects induced by traditional neuroleptic agents responds to treatment with beta-blockers? (check one)
A. Akathisia
B. Rigidity
C. Dystonia
D. Sialorrhea
E. Stooped posture
A
Rigidity, sialorrhea, and stooped posture are parkinsonian ADRS of neuroleptic drugs. These are treated with anticholinergic drugs such as benztropine or amantadine.
Dystonia also responds to anticholinergics.
Akathisia (motor restlessness and an inability to sit still) can be treated with either anticholinergic drugs or beta-blockers.
A 40-year-old nurse presents with a 1-year history of rhinitis, and a more recent onset of episodic wheezing and dyspnea. Her symptoms seem to improve when she is on vacation. She does not smoke, although she says that her husband does. Her FEV1 improves 20% with inhaled β-agonists.Which one of the following is the most likely diagnosis? (check one)
A. Occupational asthma
B. Sarcoidosis
C. COPD
D. Anxiety
E. Vocal cord dysfunction
A
Occupational asthma is often preceded by the development of rhinitis in the workplace and should be considered in patients whose symptoms improve away from work.
Reversibility with β-agonist use makes COPD less likely, in addition to the fact that the patient is a nonsmoker.
CF is not a likely diagnosis in a patient this age with a long history of being asymptomatic.
Sarcoidosis would be less likely to cause reversible airway obstruction and intermittent symptoms.
Vocal cord dysfunction would not be expected to respond to bronchodilators.
A 55-year-old male is brought to the emergency department because of confusion and seizures. He has a history of hypertension and obstructive sleep apnea due to obesity. He is not conscious and no other history is available. An examination shows no focal neurologic findings, but a general examination is limited because of his size. Breath sounds are diminished, and heart sounds are difficult to hear. He has venous insufficiency changes on his lower extremities, with brawny-type edema. Laboratory testing reveals a sodium level of 116 mmol/L (N 135–145), but normal renal and liver functions. A chest radiograph shows mild cardiomegaly. A BNP level is pending, but immediate treatment is felt to be indicated.
Which one of the following is the treatment of choice for this patient?
A. Valsartan (Diovan)
B. Furosemide
C. Vasopressin (Pitressin)
D. Hypertonic saline
E. Conivaptan (Vaprisol)
D
This patient has severe hyponatremia manifested by confusion and seizures, a life-threatening situation warranting urgent treatment with hypertonic (3%) saline. The serum sodium level should be raised by only 1–2 mmol/L per hour, to prevent serious neurologic complications. Saline should be used only until the seizures stop.
Some authorities recommend concomitant use of furosemide, especially in patients who are likely to be volume overloaded, as this patient is, but it should not be used alone.
The arginine vasopressin antagonist conivaptan is approved for the treatment of euvolemic or hypervolemic hyponatremia, but not in patients who are obtunded or in a coma, or who are having seizures.
A 16-year-old white female is brought to your office because she has been “passing out.” She tells you that on several occasions while playing in the high-school band at the end of the half-time show she has “blacked out.” She describes feeling lightheaded with spots before her eyes and tunnel vision just prior to falling. Friends in the band have told her that she appears to be pale and sweaty when these episodes occur. No seizure activity has ever been observed. In each instance she regains consciousness almost immediately; there is no postictal state. She has been seen in the emergency department for this on two occasions with normal vital signs, physical findings, and neurologic findings. A CBC, a metabolic profile, and an EKG are also normal. Which one of the following tests is most likely to yield the correct diagnosis? (check one)
A. A sleep-deprived EEG
B. 24-hour Holter monitoring
C. A pulmonary/cardiac stress test
D. An echocardiogram
E. Tilt table testing
E
Reflex syncope is a strong diagnostic consideration for episodes of syncope associated with a characteristic precipitating factor (in this case, the half-time show).
The 3 major categories of syncope include carotid sinus hypersensitivity, neurally mediated, and situational syncopes. The most common and benign forms of syncope are neurally mediated syncope aka vasovagal syncope with sudden hypotension, frequently accompanied by bradycardia. Most patients are young and otherwise healthy. The mechanism of the syncope seems to be a period of high sympathetic tone (often induced by pain or fear), followed by sudden sympathetic withdrawal, which then triggers a paradoxical vasodilatation and hypotension. Attacks occur with upright posture, often accompanied by a feeling of warmth or cold sweating, lightheadedness, yawning, or dimming of vision. If the patient does not lie down quickly he or she will fall, with the horizontal position allowing a rapid restoration of central profusion. Recovery is rapid, with no focal neurologic sense of confusion or headache. The event can be duplicated with tilt table testing, demonstrating hypotension and bradycardia.
The most serious complication of a slipped capital femoral epiphysis is: (check one)
A. Osteomyelitis
B. Pathologic fracture
C. Avascular necrosis
D. Chondrolysis
C
Avascular necrosis is the most serious complication of a slipped capital femoral epiphysis, and leads to more rapid arthritic deterioration. It may require hip fusion and total hip replacement early in adulthood.
A 39-year-old male presents to the ED with a 2-hour history of chest discomfort, dyspnea, dizziness, and palpitations. He has no history of CAD. He states that he has had several similar episodes in the last year. On examination he has a temperature of 36.8°C (98.2°F), a respiratory rate of 25/min, a heart rate of 193 beats/min, a blood pressure of 134/82 mm Hg, and an O2 saturation of 96% on room air. The physical examination is otherwise normal. An EKG reveals a regular narrow QRS complex tachycardia with no visible P waves.
He converts to normal sinus rhythm with intravenous adenosine (Adenocard). Which one of the following would be most useful in the long-term management of this patient’s condition? (check one)
A. Adenosine
B. Digoxin
C. Vagal maneuvers
D. Pacemaker placement
E. Radiofrequency ablation
E
This patient presents with a classic description of supraventricular tachycardia (SVT). The initial management of SVT centers around stopping the aberrant rhythm. In the hemodynamically stable patient initial measures should include vagal maneuvers, IV adenosine or verapamil, IV diltiazem or β-blockers, IV antiarrhythmics, or cardioversion in refractory cases. While digoxin is occasionally useful in atrial fibrillation with a rapid ventricular rate, it is not recommended for SVT. Radiofrequency ablation is fast becoming the first-line therapy for all patients with recurrent SVT and SVT that is refractory to suppressive drug therapies.
A 23-year-old gravida 3 para 1 at 28 weeks’ gestation whose blood type is O-negative is antibody positive (D antibody) on a routine 28-week screen. Which one of the following best describes the clinical significance of this finding? (check one)
A. The fetus HAS hemolytic disease and requires appropriate monitoring and treatment
B. The fetus is AT RISK for hemolytic disease only if the biological father is Rh-negative
C. The fetus is AT RISK for hemolytic disease only if the biological father is Rh-positive
D. The current fetus is NOT at risk for hemolytic disease, but subsequent pregnancies may be at risk
C
If a person is Rh(-), they do not have type D antigen on their RBCs. If a woman is exposed to D antigen (+) RBCs, she can have an immune response of variable strength. If a maternal antibody screen for D antigen is (+), this indicates that the current fetus MAY be at risk for hemolytic disease. The level of risk is determined by the antibody titer. For example, an antibody titer of 1:4 poses much less risk to the fetus than a titer of 1:64. Determination of the blood type of the father is helpful if paternity is certain. If the father is homozygous Rh (-), there is no risk of alloimmunization to the fetus and the fetus is NOT at risk for hemolytic disease. In this scenario, maternal sensitization occurred either from a prior pregnancy with a different partner or from another source (e.g., transfusion). If the father is heterozygous or homozygous Rh positive, then the fetus IS at risk. If paternity is uncertain, PCR can be performed on 2 mL of amniotic fluid or 5 mL of chorionic villi to accurately determine the fetal Rh status.
In patients with breast cancer, the most reliable predictor of survival is (check one)
A. estrogen receptor status
B. cancer stage at the time of diagnosis
C. tumor grade
D. histologic type
E. lymphatic or blood vessel involvement
B
The most reliable predictor of survival in breast cancer is the stage at the time of diagnosis, as tumor size + lymph node involvement are the main factors to take into account.
Other prognostic parameters (tumor grade, histologic type, and lymphatic or blood vessel involvement) have been proposed as important variables, but most microscopic findings other than lymph node involvement correlate poorly with prognosis. Estrogen receptor (ER) status may also predict survival, with ER-positive tumors appearing to be less aggressive than ER-negative tumors.
A 62-year-old female with numbness in the lower extremities and macrocytosis has a normal serum folate level and a serum B12 level of 200 pg/mL (N 150–800). Which one of the following laboratory findings would confirm the diagnosis of B12 deficiency? (check one)
A. Elevated angiotensin converting enzyme
B. Elevated methylmalonic acid
C. Elevated free erythrocyte protoporphyrin
D. Low haptoglobin
E. Low homocysteine
B
Some patients with significant vitamin B12 deficiency have levels in the lower range of normal, as this patient does. Vitamin B12 is a cofactor in the synthesis of both methionine and succinyl coenzyme A, and vitamin B12 deficiency leads to the accumulation of methylmalonic acid and homocysteine, which are the precursors of these compounds. An elevated level of these substances is therefore more sensitive than a low vitamin B12 level for vitamin B12 deficiency.
Homocysteine is also elevated in folic acid deficiency, however, so a methylmalonic acid level is recommended if vitamin B12 deficiency is a concern and serum vitamin B12 levels are 150–400 pg/mL.
A reduced haptoglobin level is useful to confirm hemolytic anemia.
An elevated free erythrocyte protoporphyrin level may occur in lead poisoning or iron deficiency.
An elevated angiotensin converting enzyme level is found in sarcoidosis.
A 45-year-old white male undergoes a health screening at his church. He has a carotid Doppler study, abdominal US, heel densitometry, and a multiphasic blood panel. He receives a report indicating that all of the studies are normal, but a 0.7-cm thyroid nodule was noted. The TSH level is normal. He schedules a visit with you and brings you the report. A neck examination and ENT examination are normal, and you do not detect a nodule. You recommend (check one)
A. a radionuclide thyroid scan
B. T3, T4, and calcitonin levels
C. repeat ultrasonography in 6-12 months
D. a fine-needle biopsy
E. hemithyroidectomy
C
This is a classic incidentaloma. Nodules are detected in up to 50% of thyroid sonograms and carry a low risk of malignancy (If the TSH level is normal, nuclear scanning and further thyroid studies are not necessary. Nodules smaller than 1 cm are difficult to biopsy and thyroid surgery is not indicated for what is almost certainly benign disease. It is reasonable to follow small nodules with clinical examinations and periodic sonograms.
A 70-yo African-American male who has been hospitalized for 2½ weeks for heart failure develops severe, persistent diarrhea. For the past 3 days he has had abdominal cramps and profuse, semi-formed stools without mucus or blood.
The patient’s current medications include captopril (Capoten), digoxin, furosemide, subcutaneous heparin, spironolactone, and loperamide. He has CAD, but has been relatively pain free since undergoing CABG 4 years ago. An appendectomy and cholecystectomy were performed in the past, and the patient has since been free of gastrointestinal disease.
On physical examination BP 100/80 mm Hg, P 100 beats/min and regular, and T 37.0°C (98.6°F). He has mild JVD and crackles at both lung bases. Examination of his heart is unremarkable, although there is 1+ dependent edema. His abdomen is diffusely tender without masses or organomegaly. Findings on a rectal examination are normal.
CBC, BMP, EKG, and UA are all normal. The stool examination shows numerous WBC.
Of the following, the most likely diagnosis is:
A. viral gastroenteritis
B. Clostridium difficile colitis
C. ulcerative colitis
D. gluten-sensitive enteropathy (celiac sprue)
E. digoxin toxicity
B
This patient most likely has Clostridium difficile colitis, suggested by semiformed rather than watery stool, fecal leukocytes (not seen in viral gastroenteritis or sprue), and a hospital stay greater than 2 weeks. While this disease has traditionally been associated with antibiotic use, it is posing an increasing threat to patients in hospitals and chronic-care facilities who have not been given antibiotics.
The primary sources for infection in such cases have been toilets, bedpans, floors, and the hands of hospital personnel. Prompt recognition and treatment is essential to prevent patient relapse and to minimize intramural epidemics.
The diarrhea of ulcerative colitis usually contains blood and occurs intermittently over a protracted course. Digoxin toxicity is likely to be accompanied by electrocardiographic and laboratory abnormalities, particularly hyper- or hypokalemia.
The most appropriate initial pharmacologic treatment of panic disorder is: (check one)
A. An SSRI
B. A tricyclic antidepressant
C. Valproic acid (Depakene)
D. Lithium
A
Of the following, which is the most frequent cause of seizures in the elderly?
A. Alcohol withdrawal
B. Stroke
C. Head trauma
D. Hypoglycemia
E. Dementia
B
The conditions listed are all causes of seizures. Of course, there are many other causes of seizures in the elderly, including primary and metastatic neoplasias (e.g., electrolyte disorders). However, in the geriatric population, cerebrovascular disease is the most common cause of seizures, with about 10% of stroke victims developing epileptic seizures. Seizures are more common following hemorrhagic strokes compared to nonhemorrhagic strokes.
A 25-year-old medical student reads about the benefits of moderate alcohol consumption on lipid levels and begins to drink 5 ounces of red wine a day, adding 100 calories to his diet. Assuming that his diet and exercise levels stay the same, what effect will the additional 3000 calories a month have on his body weight over the next 10 years? (check one)
A. They will have essentially no effect
B. His weight will increase by about 25 kg
C. His weight will increase slightly then stabilize
D. His normal caloric expenditure will decrease
C
There is not a direct relation between daily calorie consumption and weight. An adult male consuming an extra 100 calories a day above his caloric need will not continue to gain weight indefinitely; rather, his weight will increase to a certain point and then become constant. Fat must be fed, and maintaining the newly created tissue requires an increase in caloric expenditure. An extra 100 calories a day will result in a weight gain of approximately 5 kg, which will then be maintained.
A male infant is delivered by cesarean section because of dystocia due to macrosomia. Apgar scores are 8 at 1 minute and 10 at 5 minutes. However, at about 1 hour of age he begins to have tachypnea without hypoxemia. A chest radiograph shows diffuse parenchymal infiltrates and fluid in the pulmonary fissures. The symptoms resolve without treatment within 24 hours. The most likely diagnosis is (check one)
A. transient tachypnea of the newborn
B. intracranial hemorrhage
C. laryngotracheomalacia
D. meconium aspiration syndrome
E. hyaline membrane disease
A
This child had transient tachypnea of the newborn, the most common cause of neonatal respiratory distress. It is a benign condition due to residual pulmonary fluid remaining in the lungs after delivery. Risk factors include cesarean delivery (no vaginal squeeze to eliminate the lung fluid), macrosomia (increased likelihood of C-sections), male gender, and maternal asthma and/or diabetes mellitus.
When draining a felon, which one of the following incisions is recommended? (check one)
A. A “fishmouth” bilateral incision
B. A “hockey stick” J-shaped incision including the distal and lateral aspects of the digit
C. A transverse volar incision
D. A high lateral incision
D
When draining a felon, a volar longitudinal incision or a high lateral incision is recommended. Incisions that are not recommended are the “fish-mouth” incision, the “hockey stick” (or “J”) incision, and the transverse palmar incision
A 28-year-old female consults you because of fatigue, arthralgias that are worse in the morning, and painful, swollen finger joints. She is a high-school teacher. Her erythrocyte sedimentation rate is 60 mm/hr and a test for rheumatoid factor is strongly positive.
The best choice for initial therapy would be: (check one)
A. prednisone
B. aspirin
C. naproxen (Naprosyn)
D. rituximab (Rituxan)
E. methotrexate (Rheumatrex)
E
DMARDs such as methotrexate are the best initial therapy for RA. Aspirin and NSAIDs are no longer considered first-line treatment because of concerns about their limited effectiveness, inability to modify the long-term course of the disease, and gastrointestinal and cardiotoxic effects.
A 27-year-old female presents to the emergency department with a complaint of bloody diarrhea and abdominal cramping. A few days ago she ate a rare hamburger at a birthday party for her 4-year-old son. He ate hot dogs instead, and has not been ill. A stool specimen is positive forEscherichia coli O:157.
Which one of the following should you do next? (check one)
A. Provide levofloxacin (Levaquin) prophylaxis to her close contacts
B. Monitor her liver enzymes
C. Monitor her renal function
D. Reassure her that her son is not at risk of illness
C
Escherichia coli O:157 can cause serious GI illness; source is undercooked beef. Transmission is frequent, esp in children’s day-care facilities / nurseries. Patients present with bloody diarrhea. This patient has a 10%–15% risk of developing hemolytic uremic syndrome secondary to her E. coli O:157 infection, making close monitoring of renal function essential.
The Strength-of-Recommendation Taxonomy (SORT) is used to grade key recommendations in clinical review articles. Which one of the following grades indicates that a recommendation is based on consistent, good-quality, patient-oriented evidence? (check one)
A. A
B. B
C. C
D. X
A
When possible, it is important for the family physician to base clinical decisions on the best evidence. Strength-of-Recommendation Taxonomy (SORT) grades in medical literature are intended to help physicians practice evidence-based medicine. SORT grades are only A, B, and C.
- SOR A - recommendation based on consistent, good-quality, patient-oriented evidence.
- SOR B - recommendation based on limited-quality patient-oriented evidence.
- SOR C - recommendation based on consensus, disease-oriented evidence, usual practice, expert opinion, or case series for studies of diagnosis, treatment, prevention, or screening.
These should not be confused with the U.S. FDA labeling categories for the potential teratogenic effects of medications on a fetus: pregnancy categories A, B, C, D, and X.
You see a 1-year-old male for a routine well child examination. Laboratory tests reveal a hemoglobin level of 10 g/dL (N 9–14), a hematocrit of 31% (N 28–42), a mean corpuscular volume of 68 :m3 (N 70–86), and a mean corpuscular hemoglobin concentration of 25 g/dL (N 30–36). A trial of iron therapy results in no improvement and a serum lead level is normal. Which one of the following would be the most appropriate test at this time?
A. Hemoglobin electrophoresis
B. Bone marrow examination
C. Vitamin B12 and folate levels
D. A TSH level
A
This patient has a microcytic, hypochromic anemia, which can be caused by iron deficiency, thalassemia, sideroblastic anemia, and lead poisoning. In a child with a microcytic anemia who does not respond to iron therapy, hemoglobin electrophoresis is appropriate to diagnose thalassemia. Hypothyroidism, vitamin B12 deficiency, and folate deficiency result in macrocytic anemias.
In the United States, the number of deaths has increased in recent years for which one of the following vaccine-preventable illnesses? (check one)
A. Tetanus
B. Hepatitis C
C. Rubella
D. Pertussis
E. West Nile virus
D
In the US, deaths from pertussis increased from 4 deaths in 1996 to 17 deaths in 2001, and a total of 56 deaths from 2001 to 2003. Immunity has decreased in previously vaccinated adolescents and adults, and now they are a reservoir for infection. Tdap vaccine is recommended as a single booster for patients age 19–65, and those between the ages of 11 and 18 years should receive Tdap rather than a Td booster. The Tdap vaccine protects against pertussis, in addition to tetanus and diphtheria. Tetanus and rubella deaths are not increasing. There are no vaccines for hepatitis C or West Nile virus.
A 30-year-old gravida 3 para 2 at 28 weeks’ gestation is a restrained passenger in a high-speed motor vehicle accident. After initial stabilization in the field with supplemental oxygen and intravenous fluids, she is brought into the emergency department on a backboard and wearing a cervical collar. Until you are able to rule out a spinal injury, in what position should the patient be kept? (check one)
A. Supine
B. Supine, with the uterus manually deflected laterally
C. Prone
D. Trendelenburg’s position
E. Left lateral decubitus
B
In general, it is best to place a woman who is > 20 weeks pregnant in the left lateral decubitus position because the uterus can compress the great vessels, resulting in decreased SBP and uterine blood flow. However, in the case of trauma where a spinal cord injury cannot be ruled out, the woman needs to be kept supine on a backboard. The weight of the uterus can be shifted off the great vessels by either manual deflection laterally or by elevating the right hip 4–6 inches by placing towels under the backboard.
The Trendelenburg position does not relieve the weight of the uterus on the great vessels. The prone position does not provide adequate spinal cord protection, and would be extremely awkward in a large pregnant woman.
To be eligible for Medicare hospice benefits, a patient must: (check one)
A. be enrolled in Medicare Part D
B. be referred to hospice by a physician
C. be debilitated and moribund
D. have a malignancy
E. have an estimated life expectancy of less than 6 months
E
To be eligible for Medicare hospice benefits, a patient must be eligible for Medicare Part A (hospital insurance). Although most hospice referrals come from physicians, nurses, and social workers, a patient’s family members can also make a hospice referral. The patient must sign a statement choosing hospice, and both the patient’s physician and the hospice medical director must certify that the patient has a terminal illness with an estimated life expectancy of less than 6 months. There is no requirement that the patient be debilitated or moribund.
Which one of the following cardiovascular changes is a recognized age-related effect?
A. Decreased maximal heart rate with exercise
B. Decreased myocardial collagen
C. Decreased myocardial mass
D. Increased left ventricular compliance
E. Increased heart rate at rest
A
Maximal HR with exercise generally decreases with age. A frequently used formula for predicting maximal HR = (220 - age) x (0.85 if female)
Myocardial collagen and mass both increase with age. The increase in collagen may play a role in decreasing left ventricular compliance. The resting heart rate, like the maximal exercising heart rate, decreases with normal aging. Tachycardia at rest may suggest a pathologic state.
A 25-year-old white female comes to your office complaining of abdominal pain. She requests that you hospitalize her and do whatever is necessary to get rid of the pain that has been present for a number of years. She has difficulty describing the pain. She is a divorced single parent, and becomes defensive when asked about her former marriage, stating only that her ex-husband is an alcoholic, “just like my father.”
Her previous medical history includes an appendectomy, a cholecystectomy, and a hysterectomy. On physical examination she appears healthy, and a CBC, erythrocyte sedimentation rate, serum amylase level, and comprehensive metabolic panel are all normal.
Management of this patient should include which one of the following?
A. Reassurance that her symptoms are simply psychogenic
B. Long-term use of antidepressants
C. Scheduling frequent, regular office visits
D. Hospitalization, then consultation with a psychiatrist
E. Referral to a surgeon for exploratory laparotomy
C
A 15-year-old male has a 1-week history of a nonproductive cough, a low-grade fever, a sore throat, and hoarseness. His respiratory rate is 22/min but unlabored, his temperature is 38.1°C (100.6°F), and his O2 saturation is 94% on room air. A chest radiograph reveals bilateral interstitial infiltrates. Which one of the following treatments would be most appropriate for this patient?
A. Ceftriaxone (Rocephin)
B. Amoxicillin
C. Cefdinir
D. Linezolid (Zyvox)
E. Azithromycin (Zithromax)
E
Community-acquired pneumonia in children > 5 yo is commonly due to Mycoplasma pneumo, Chlamydophila pneumo, and Strep pneumo. Less common bacterial infections include H. influenzae, Staph aureus, and group A Strep.
Initial treatment with antibiotics is empiric, as the pathogen is usually unknown at the time of diagnosis. The choice in children is based on age, severity of illness, and local patterns of resistance. Children age 5–16 years who can be treated as outpatients are usually treated with oral azithromycin.
For patients requiring inpatient management, IV cefuroxime PLUS IV erythromycin or azithromycin is recommended
A 47-year-old female presents to your office complaining of hot flashes and cold sweats of several months’ duration. She is premenopausal. Which one of the following is accurate advice for this patient regarding vasomotor symptoms? (check one)
A. They usually peak around the time of menopause, then decline after menopause
B. Without treatment, they usually get worse each year after menopause
C. They are always caused by estrogen deficiency
D. Estrogen alone is recommended for therapy
A
Vasomotor symptoms slowly increase until perimenopause, at which time they peak. The symptoms then tend to diminish after menopause.
Numerous other pathologic and functional vasomotor etiologies may mimic hot flashes.
Estrogen is effective in treating hot flashes but generally should not be given alone, as it increases the risk for endometrial cancer.
A 47-year-old male is preparing for a 3-day trip to central Mexico to present the keynote address for an international law symposium. He asks you for an antibiotic to be taken prophylactically to prevent bacterial diarrhea.
Which one of the following would you recommend? (check one)
A. Trimethoprim/sulfamethoxazole (Bactrim, Septra)
B. Rifaximin (Xifaxan)
C. Doxycycline
D. Nitrofurantoin (Macrobid)
B
Rifaximin, a nonabsorbable antibiotic, has been shown to reduce the risk for traveler’s diarrhea by 77%.
Which one of the following laboratory test results would confirm a diagnosis of vitamin B12 deficiency? (check one)
A. Low epogen
B. Low folic acid
C. High methylmalonic acid (MMA)
D. Low homocysteine
E. A normal peripheral smear
C
Patients with renal failure often have normal vitamin B12 levels despite an actual deficiency. In this situation, the clinician can order a methylmalonic acid (MMA) level to confirm the diagnosis. Vitamin B12 is the necessary coenzyme in the metabolism of MMA to succinyl-CoA. Thus, in the absence of vitamin B12, MMA levels increase. Additionally, homocysteine levels would be elevated in the presence of vitamin B12 deficiency
A 35-year-old white male presents to the emergency department with chest pain of 30 minutes duration. He describes the pain as feeling like pressure on his chest, and says it radiates into his left arm. It is accompanied by dyspnea, diaphoresis, anxiety, and palpitations. His past medical history is unremarkable and he has no family history of premature heart disease. He smokes 2 packs of cigarettes per day and admits to intranasal cocaine use 2 hours ago.
Vital signs include a blood pressure of 180/110 mm Hg, a pulse rate of 110 beats/min, a respiratory rate of 24/min, and a temperature of 37.2°C (99.0°F). Other than the anxiety and diaphoresis, the general examination is unremarkable. An EKG shows sinus tachycardia with an early repolarization pattern. Aspirin and nitroglycerin have been administered, as well as oxygen via nasal cannula. Which one of the following would be most appropriate at this point?
A. Nifedipine (Procardia)
B. Enalaprilat intravenously
C. Lorazepam (Ativan) intravenously
D. Metoprolol (Toprol) intravenously
E. Thrombolytic therapy
C
Treatment of cocaine-associated chest pain is similar to that of acute coronary syndrome, unstable angina, or acute MI, but there are exceptions. The hypertension, tachycardia, and chest pain will often respond to IV benzodiazepines as early management.
While β-blockers are recommended for acute MI, they can exacerbate coronary artery spasm in cocaine-associated chest pain.
Fibrinolytic therapy should be given only to patients who clearly have an STEMI and cannot receive immediate direct PCI.
Calcium channel blocker use in the setting of cocaine-induced ischemia has not been studied, but may be considered if there is no response to benzodiazepines and NTG.
There are no recommendations regarding the use of ACEi, but these agents would not address the tachycardia.
For which type of renal calculus is acidification of the urine indicated?
A. Cystine
B. Uric acid
C. Calcium oxalate
D. Calcium phosphate
D
Uric acid, cystine, and calcium oxalate stones tend to form in acidic urine, whereas struvite (magnesium ammonium phosphate) and calcium phosphate stones form in alkaline urine. Urine should be acidified for prevention of calcium phosphate and struvite stones. Cranberry juice or betaine can lower urine pH.
Acidic = Uric, Cystine, Oxalate -> treat with base
Basic = mag ammonium phosphate, calcium phosphate (phosphate) -> treat with acid
A 20-year-old college wrestler is seen for an examination prior to the wrestling season. He tells you that some friends have told him he should start taking dehydroepiandrosterone (DHEA), and he asks for your advice. Which one of the following is true about the effects of this drug?
A. It enhances performance but not muscle strength
B. It enhances muscle strength but not performance
C. It enhances both performance and muscle strength
D. It does not enhance either performance or muscle strength
D
Dehydroepiandrosterone (DHEA) is illegal under the Anabolic Steroid Control Act of 2004, and is prohibited by the NCAA and the International Olympic Committee. Like androstenedione, DHEA is a precursor to testosterone, but neither of these substances has been shown to enhance either performance or strength. In fact, they increase serum estrogen and LH levels.
A 26-year-old male presents with hand pain. He tells you he was out drinking with friends last night and does not remember sustaining any injuries. On examination, there is diffuse swelling and tenderness across the dorsal and lateral aspects of the hand. Radiographs are shown inFigures 8 and 9.
Which one of the following would be the most appropriate treatment? (check one)
A. A wrist extension splint
B. A molded finger splint
C. A ulnar gutter splint
D. A short arm cast
E. Surgical pin fixation
C
In the xray shown, there is a fracture of the fifth metacarpal head, commonly known as a boxer’s fracture. There is only slight volar angulation and no displacement. The proper treatment for this fracture is an ulnar gutter splint, which immobilizes the wrist, hand, and fourth and fifth digits in the neutral position. Generally, 3 or 4 weeks of continuous splinting is adequate for healing.
Surgical pinning is indicated in cases of significant angulation (35°–40° or more of volar angulation) or in fractures with significant rotational deformity or displacement. The other options listed are not appropriate treatments for this injury. This injury most commonly results from “man-versus-wall” pugilistics, but other mechanisms of injury are possible.
Which one of the following drugs inhibits platelet function for the life of the platelet? (check one)
A. Aspirin
B. Ibuprofen
C. Dipyridamole (Persantine)
D. Ticlopidine (Ticlid)
E. Warfarin (Coumadin)
A
Aspirin is the only drug that interferes with platelet aggregation for the life of the platelet. It does this by permanently acetylating cyclooxygenase, thus inhibiting prostaglandin synthesis. This phenomenon is clinically helpful when an antithrombotic effect is desired, but it may require that surgical procedures be delayed, as the effect of a single aspirin on bleeding times can persist for up to 5 days.
Other NSAIDs (i.e., indomethacin, sulfinpyrazone) also inhibit platelet activity, but their effect on prostaglandin synthesis is reversible.
The anti-platelet effect of dipyridamole is less well understood.
Warfarin is a biochemical antagonist of prothrombin and vitamin K-dependent coagulation factors, and therefore has no significant effect on platelet activity.
Which one of the following surgical procedures is associated with the highest risk for perioperative myocardial ischemia? (check one)
A. Femoropopliteal bypass
B. Pulmonary lobectomy
C. Hip arthroplasty
D. Transurethral resection of the prostate
E. Mastectomy
E
Surgical procedures associated with a high (>5%) risk of perioperative myocardial ischemia include vascular surgery and emergent major operations, especially in patients over 75 years of age.
Head/neck surgery, intraperitoneal and intrathoracic surgery, orthopedic surgery, and prostate surgery carry an intermediate risk (1%–5%)
Endoscopic procedures and cataract and breast surgeries are considered low-risk (
The pruritic lesions on the arm shown in Figure 6 are typical of: (check one)
A. poison ivy dermatitis
B. brown recluse spider bites
C. bedbug bites
D. Hymenoptera stings
E. molluscum contagiosum
C
Bedbug bites are difficult to diagnose due to the variability in bite response between people and the changes in a given individual’s skin reaction over time. It is best to collect and identify bedbugs to confirm bites. Cimex lectularius injects saliva into the bloodstream of the host to prevent coagulation. It is this saliva that causes the intense itching and welts.
An 80-year-old white male is admitted to the hospital with an acute myocardial infarction. He is given an antiarrhythmic for ventricular ectopic beats. During monitoring in the coronary care unit, he develops the rhythm shown on the EKG in Figure 3.
This rhythm is best described as: (check one)
A. ventricular flutter
B. ventricular fibrillation
C. ventricular tachycardia
D. torsades de pointes
D
Torsades de pointes - wide QRS complexes with apices that are sometimes positive and sometimes negative; generally associated with QT prolongation.
Anything that produces or is associated with a prolonged QT interval can cause torsades de pointes, including drugs (quinidine, procainamide, disopyramide, phenothiazines), electrolyte disturbances, insecticide poisoning, subarachnoid hemorrhage, and congenital QT prolongation. The the usual anti-arrhythmic drugs are not only useless but contraindicated, because they can make matters worse.
An 84-year-old male is walking across the street and has to hurry to avoid oncoming traffic. He suddenly develops extreme pain in his knee and falls to the street, and has to be carried to the sidewalk.
The following day he comes to the emergency department. He is comfortable when placed in a knee immobilizer, but is very tender just above the patella. He can bend his knee, but when he tries to straighten his leg it is so weak that he cannot move it at all. Radiographs of the knee are shown in Figure 4.
What is the most likely diagnosis? (check one)
A. Patellar tendon rupture
B. Quadriceps tendon rupture
C. Tibial plateau fracture
D. Patellar subluxation
E. Lumbar radiculopathy
B
Quadriceps tendon rupture can be partial or complete. When complete, as in this case, the patient has no ability to straighten the leg actively. A similar pattern is seen with patellar tendon rupture, but in this situation the patella is retracted superiorly by the quadriceps.
A 65-year-old female who is morbidly obese presents to your office with intertrigo in the axilla. On examination you detect small, reddish-brown macules that are coalescing into larger patches with sharp borders. You suspect cutaneous erythrasma complicating the intertrigo.
What would be the most appropriate topical treatment for this condition? (check one)
A. Cornstarch
B. A mild corticosteroid lotion
C. A high-potency corticosteroid lotion
D. Erythromycin
D
Intertrigo is inflammation of skinfolds caused by skin-on-skin friction. Secondary cutaneous bacterial and fungal infections are common complications. For example, Corynebacterium minutissimum infection (erythrasma) can result in small reddish-brown macules that may coalesce into larger patches with sharp borders. Treatment involves topical or oral erythromycin.
Cutaneous erythrasma may complicate intertrigo of interweb areas, intergluteal and crural folds, axillae, or inframammary regions.
A 53-year-old male presents with a 1-day history of swelling in his upper arm, shown in Figure 1. The swelling appeared after a sudden painful “pop” as he was lifting a heavy box. A physical examination reveals a soft to firm, nontender mass in the anterior aspect of the arm, and weakness of forearm supination. Shoulder radiographs are normal.
Which one of the following is the most likely diagnosis? (check one)
A. Acute anterior shoulder dislocation
B. Lateral epicondylitis
C. Biceps tendinitis
D. Biceps tendon rupture
D
Biceps tendon rupture is one of the most common musculotendinous ruptures. Patients typically present with a visible lump in the upper arm following an audible, painful “pop.” The injury typically results from application of an eccentric load to a flexed elbow. Risk factors for biceps tendon rupture include age >40, deconditioning, contralateral biceps tendon rupture, a history of rotator cuff tear, rheumatoid arthritis, and cigarette smoking. Weakness in forearm supination and elbow flexion may be present. The biceps squeeze test and the hook test are both sensitive and specific for diagnosing the condition.
Acute anterior shoulder dislocation is typically very painful, with restricted shoulder movements. Lateral epicondylitis results in pain and tenderness over a localized area of the proximal lateral forearm. Biceps tendinitis results in a deep throbbing pain over the anterior shoulder, accompanied by bicipital groove tenderness.
A 90-year-old female nursing-home patient has a 1.5×2.0-cm lesion on her face (shown inFigure 8). She states that the “spot” has been present for years and that it doesn’t bother her. Closer examination reveals a flat maculopapular lesion with varying colors and an irregular border.
Which one of the following is the most likely diagnosis? (check one)
A. Actinic keratosis
B. Metastatic breast carcinoma
C. Seborrheic keratosis
D. Lentigo maligna melanoma
E. Basal cell carcinoma
D
This patient has a malignant melanoma, often called lentigo maligna melanoma. These lesions typically appear during the seventh or eighth decade of life, and are most often located on the face. This patient’s age, health status, and wishes must be considered in any treatment plans. The other skin lesions listed can be seen in this age group, but they are easily distinguished from this malignant lesion.
Fibromyalgia is characterized by tender trigger points (check one)
A. along the medial border of each scapula
B. bilaterally at the anatomic snuffbox
C. at the insertion of the Achilles tendon into the posterior heel
D. at the second and third web spaces on the plantar surface of the foot
A
The typical fibromyalgia trigger points lie along the medial scapula borders, as well as the posterior neck, upper outer quadrants of the gluteal muscles, and medial fat pads of the knees. Tenderness of the anatomic snuffbox, Achilles tendons, or web spaces of the toes would most likely be related to another diagnosis.
An 8-year-old white male presents with a 4-day history of erythematous cheeks, giving him a “slapped-cheek” appearance. Examination of the extremities reveals a mildly pruritic, reticulated, erythematous, maculopapular rash (see Figure 1). He is afebrile and no other constitutional symptoms are present.
he most likely etiologic agent is
(check one)
A. human parvovirus
B. adenovirus
C. cytomegalovirus
D. coxsackievirus
A
Erythema infectiosum is caused by parvovirus B19. It presents with the typical viral prodrome, along with mild upper respiratory symptoms. The hallmark rash has three stages:
- Stage 1: facial flushing/“slapped cheek”
- Stage 2: exanthem spreads concurrently to the trunk and proximal extremities as a diffuse macular erythematous rash
- Stage 3: central clearing of this rash creates a lacy, reticulated appearance, as seen in the figure. This rash tends to be on the extensor surfaces and spares the palms and soles.
It resolves in 1–3 weeks but can recur with heat, stress, and exposure to sunlight.
A 5-year-old male fell while playing and complained that his wrist hurt. The next day he is brought to your office because he refuses to use his arm. Which one of the following best describes the condition seen in the radiographs shown in Figure 9?
A. A normal appearance
B. A radial fracture
C. An ulnar fracture
D. A radioulnar fracture
E. Indeterminate result
B
Radial fractures are the most common fracture in this age group, but can be missed on xray. The bend in the cortex of the distal radius indicates the fracture. It will heal with almost any choice of treatment. Most clinicians opt for casting to reduce the chance of reinjury during the first few weeks of healing, but the parents’ preferences in this regard are important. Some pediatric long-bone fractures involve growth plates, and the results can be indeterminate, requiring either more advanced imaging or comparison views of the opposite limb.
One week after returning from a Caribbean vacation, a 43-year-old female presents to a walk-in clinic with a complaint of redness and itching on the sole of her foot, shown in Figure 2. She recalls experiencing a stinging sensation in the same area while she was wading in the surf on the day before she was to return home, but was unable to see any sign of injury immediately following the incident. Since her return the itching has intensified and the red area has enlarged.
C
Cutaneous larva migrans occur when third-stage hookworm larvae penetrate the skin and migrate through the dermis, creating the serpiginous, erythematous tracks. Most encountered in tropical and semitropical regions such as the Caribbean, Africa, Asia, and South America.
Travelers to beach environments where pet feces have been previously deposited are most at risk because of the direct contact of bare skin with the sand. As in this case, a stinging or itching sensation may be noted upon penetration; this is followed by the development of the creeping eruption, which usually appears 1–5 days later, although the onset may be delayed for up to a month. The larvae will not develop in the human host, so the infection is self-limited, usually resolving within weeks to months. Treatment with antihelminthic drugs can greatly reduce the clinical course. Preventive measures include treatment of infected dogs and cats and limiting exposure to contaminated soil by wearing shoes and protective clothing.
A 25-year-old female is in active labor at term and is dilated to 7 cm. An electronic fetal monitoring tracing is shown in Figure 5. Which one of the following is a possible etiology for this fetal heart rate pattern?
A. Normal progress of labor
B. Maternal fever
C. Effects of epidural anesthesia
D. Post-dates pregnancy
E. Umbilical cord prolapse
B
This tracing shows fetal tachycardia, defined as a baseline fetal heart rate >160 beats/min for at least 15 minutes. Causes include maternal fever, fetal hypoxia, hyperthyroidism, maternal or fetal anemia, medication effects of parasympatholytic or sympathomimetic drugs, chorioamnionitis, fetal tachyarrhythmia, and prematurity.
Fetal tachycardia is not a sign of normal progression of labor. Epidural anesthesia, post-dates pregnancy, and umbilical cord prolapse would all be causes of fetal bradycardia.
A 68-year-old white female with a several-year history of well-controlled essential hypertension and a history of acute myocardial infarction 2 years ago is brought to the emergency department complaining of sudden, painless, complete loss of vision in her left eye that began 1 hour ago. Her vital signs are stable, and her blood pressure is 148/90 mm Hg. Her corrected visual acuity is: left—absent, with no light perception; right—20/30. The external eye examination is entirely unremarkable. A retinal examination reveals the findings shown in Figure 5. The most likely diagnosis is: (check one)
A. acute narrow-angle glaucoma
B. optic neuritis
C. retinal hemorrhage
D. central retinal artery occlusion
E. central retinal vein occlusion
D
The retinal findings shown are consistent with central retinal artery occlusion. The painless, unilateral, sudden loss of vision over a period of seconds may be caused by thrombosis, embolism, or vasculitis.
Acute narrow-angle glaucoma is an abrupt, painful, monocular loss of vision often associated with a red eye, which will lead to blindness if not treated.
In persons with optic neuritis, funduscopy reveals a blurred disc and no cherry-red spot.
Occlusion of the central retinal vein causes unilateral, painless loss of vision, but the retina will show engorged vessels and hemorrhages
At a routine annual visit, a 31-year-old inner-city elementary school teacher asks you about a lesion on the nail of her ring finger, shown in Figure 8. On examination, you note that her other nails all have a slight linear depression or groove. Which one of the following is the most likely cause of this problem?
A. A paronychial fungal infection
B. Psoriasis
C. Iron deficiency
D. Lead exposure
E. A traumatic/metabolic event
E
Fingernails and toenails document a history of the body during the past several months. The symmetric depression across the nail plate growing toward the distal edge of the nail shown here represents significant trauma to the body some weeks ago. These classic lines are called Beau’s lines. No treatment is required.
A 12-year-old male who lives on a farm presents with lesions on his toes (shown in Figure 7). Which one of the following items from the patient’s history is relevant to the diagnosis?
A. Recent tooth extraction and gingival surgery
B. A family history of systemic lupus erythematosus
C. Recurrent fevers for the past 2 weeks
D. Exposure to cold temperatures
E. Vaccination of the sheep he is raising for a 4-H project
D
Pernio (chilblains) - localized inflammatory lesion of the skin, usually found in the extremities following exposure to nonfreezing cold temperatures. It is generally a benign condition, and is not associated with any systemic, infectious, or connective tissue diseases. These lesions are red-purple plaques with deep swelling, and are accompanied by itching or burning.
Which one of the following best describes the condition seen in the radiograph in Figure 6?
A. Osgood-Schlatter disease
B. Legg-Calvé-Perthes disease
C. Blount’s disease
D. Slipped capital femoral epiphysis
E. A normal hip
D
The radiograph shows a typical slipped capital femoral epiphysis, with the epiphysis displaced posteriorly and medially. The problem usually occurs in late childhood or adolescence.
Osgood-Schlatter disease involves the anterior tibial tubercle.
Legg-Calvé-Perthes disease is avascular necrosis of the femoral head.
Blount’s disease involves the medial portion of the proximal tibia.
A 3-year-old female is brought to your office with a 3-hour history of skin lesions that are prominent, warm, papular, and serpiginous (see Figure 3). Which one of the following is the most likely cause of these lesions?
A. Heredity
B. Physical abuse
C. Infection
D. A topical agent
E. An oral medication
E
Acute urticaria occurs when an allergen activates mast cells in the skin, and is commonly caused by oral and parenteral drugs, food, and, less frequently, infections.
Topical agents and physical abuse are unlikely to present in this manner, and hereditary angioedema is more a systemic illness than a skin disorder
A 25-year-old male presents to your office for evaluation of pain in the right index finger that has been present for the past 4 days. The pain has been getting progressively worse. On examination the finger is swollen and held in a flexed position. The pain increases with passive extension of the finger, and there is tenderness to palpation from the tip of the finger into the palm.
Which one of the following is the most appropriate management of this patient? (check one)
A. Surgical drainage and antibiotics
B. Antiviral medication
C. Oral antibiotics and splinting
D. Needle aspiration
E. Corticosteroid injection
A
This patient has pyogenic tenosynovitis. When early tenosynovitis (within 48 hours of onset) is suspected, treatment with antibiotics and splinting may prevent the spread of the infection. However, this patient’s infection is no longer in the early stages and is more severe, so it requires surgical drainage and antibiotics. A delay in treatment of these infections can lead to ischemia of the tendons and damage to the flexor tendon and sheath. This can lead to impaired function of the finger.
A 39-year-old female presents with lower abdominal/pelvic pain. On examination, with the patient in a supine position, you palpate the tender area of her abdomen. When you have her raise both legs off the table while you palpate the abdomen, her pain intensifies.
Which one of the following is the most likely diagnsois?
A. Appendicitis
B. A hematoma within the abdominal wall musculature
C. Diverticulitis
D. Pelvic inflammatory disease
E. An ovarian cyst
B
Carnett’s sign - easing of the pain of abdominal palpation with tightening of the abdominal muscles. If the cause is visceral, the taut abdominal muscles could guard the source of pain from the examining hand. In contrast, intensification of pain with this maneuver points to a source of pain within the abdominal wall itself.
A 7-year-old male complains of left shoulder pain after a bicycle accident. The neurovascular evaluation is normal. A radiograph is shown in Figure 4.
D
Fractures of the medial third of the clavicle in pediatric patients are common and are best treated by a figure-of-8 apparatus. Open surgical reduction with intramedullary fixation will minimize angular deformity at the fracture site but leaves a scar and may result in nonunion. With the rare exception of neurovascular injury accompanying the fracture, there are no indications for open reduction of a clavicular fracture in a child.
A 20-year-old female distance runner presents with a 1-month history of left knee pain. The pain is worse with her first few steps in the morning and when going down stairs. Examination of the knee reveals no deformity, effusion, or ligamentous laxity. The knee joint and surrounding tissues are not tender to palpation, with the exception of an area 2 cm proximal to the left lateral joint line. What is the most likely cause of this patient’s pain?
A. Osteoarthritis of the knee joint
B. Pes anserine bursitis
C. Iliotibial band syndrome
D. Chronic lateral meniscal tear
E. Osgood-Schlatter disease
C
This case illustrates the classic history and physical findings of iliotibial band syndrome. Pain occurs most frequently at the site where the tendon crosses over the lateral femoral epicondyle.
With osteoarthritis or a meniscal tear there would be pain in the joint space with palpation.
Osgood-Schlatter disease is more common in younger adolescents and is characterized by tenderness of the tibial tubercle at the distal insertion of the patellar ligament.
Pes anserine bursitis is characterized by pain in the medial knee distal to the joint space, at the conjoined tendon of the sartorius, gracilis, and semitendinosus.
A 35-year-old right-handed softball player injures his left wrist when sliding into second base. When he sees you the next day his description of the injury indicates that he hyperextended his wrist while sliding, and the pain was later accompanied by swelling. Your examination is remarkable only for mild swelling and tenderness of the dorsal wrist, distal to the ulnar styloid. A radiograph of the wrist is shown in Figure 2. Which one of the following best describes this injury?
A. Triquetral fracture
B. Scaphoid (navicular) fracture
C. Lunate fracture
D. Lunate dislocation
E. Wrist sprain
A
Triquetral fractures typically occur with hyperextension of the wrist. Tenderness on dorsal wrist on the ulnar side distal to the ulnar styloid. The typical radiologic finding is a small bony avulsion visible on a lateral view of the wrist. Avulsion fractures respond well to 4 weeks of splinting and protection.
